00
Correct
00
Incorrect
00 : 00 : 0 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - A patient with a previous history of painless rectal bleeding episodes is found...

    Correct

    • A patient with a previous history of painless rectal bleeding episodes is found to have a Meckel's diverticulum during a colonoscopy.

      Which ONE statement about Meckel's diverticulum is accurate?

      Your Answer: They receive their blood supply from the mesentery of the ileum

      Explanation:

      A Meckel’s diverticulum is a leftover part of the vitellointestinal duct, which is no longer needed in the body. It is the most common abnormality in the gastrointestinal tract, found in about 2% of people. Interestingly, it is twice as likely to occur in men compared to women.

      When a Meckel’s diverticulum is present, it is usually located in the lower part of the small intestine, specifically within 60-100 cm (2 feet) of the ileocaecal valve. These diverticula are typically 3-6 cm (approximately 2 inches) long and may have a larger opening than the ileum.

      Meckel’s diverticula are often discovered incidentally, especially during an appendectomy. Most of the time, they do not cause any symptoms. However, they can lead to complications such as bleeding (25-50% of cases), intestinal blockage (10-40% of cases), diverticulitis, or perforation.

      These diverticula run in the opposite direction of the intestine’s natural folds but receive their blood supply from the ileum mesentery. They can be identified by a specific blood vessel called the vitelline artery. Typically, they are lined with the same type of tissue as the ileum, but they often contain abnormal tissue, with gastric tissue being the most common (50%) and pancreatic tissue being the second most common (5%). In rare cases, colonic or jejunal tissue may be present.

      To remember some key facts about Meckel’s diverticulum, the rule of 2s can be helpful:
      – It is found in 2% of the population.
      – It is more common in men, with a ratio of 2:1 compared to women.
      – It is located 2 feet away from the ileocaecal valve.
      – It is approximately 2 inches long.
      – It often contains two types of abnormal tissue: gastric and pancreatic.
      – The most common age for clinical presentation is 2 years old.

    • This question is part of the following fields:

      • Surgical Emergencies
      32
      Seconds
  • Question 2 - A 6 month old girl is brought into the emergency department with a...

    Incorrect

    • A 6 month old girl is brought into the emergency department with a history of being submerged in the pool while swimming with her parents. One of the parents explains that the child was floating on a pool noodle when a wave hit, causing the child to fall off the noodle. The child was not wearing any flotation devices and it took approximately 1 minute to find and rescue her from the water. Your consultant mentions that the child's diving reflex would have been activated. Which of the following statements accurately describes the diving reflex?

      Your Answer: Stimulated by increased pressure on the tympanic membrane during submersion

      Correct Answer: Results in peripheral vasoconstriction

      Explanation:

      The diving reflex occurs when the face comes into contact with cold water, leading to apnoea, bradycardia, and peripheral vasoconstriction. This response helps decrease the workload on the heart, lower oxygen demand in the heart muscle, and ensure adequate blood flow to the brain and vital organs. The trigeminal nerve (CN V) is responsible for transmitting sensory information, while the vagus nerve (CN X) primarily controls the motor response. This reflex is more prominent in young children and is believed to contribute to their improved survival rates in prolonged submersion in cold water.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

    • This question is part of the following fields:

      • Respiratory
      37.7
      Seconds
  • Question 3 - A 5 year old girl is brought into the emergency department after stepping...

    Correct

    • A 5 year old girl is brought into the emergency department after stepping on a sharp object while playing barefoot in the backyard. The wound needs to be stitched under anesthesia. While obtaining parental consent from the accompanying adult, you notice that the adult has a different last name than the child. When asking about their relationship to the child, the adult states that they are the child's like a mother and is the partner of the girl's father. What is the term used to describe a parent or guardian who can provide consent on behalf of a child?

      Your Answer: Parental responsibility

      Explanation:

      Parental responsibility encompasses the legal rights, duties, powers, responsibilities, and authority that a parent holds for their child. This includes the ability to provide consent for medical treatment on behalf of the child. Any individual with parental responsibility has the authority to give consent for their child. If a father meets any of the aforementioned criteria, he is considered to have parental responsibility. On the other hand, a mother is automatically granted parental responsibility for her child from the moment of birth.

      Further Reading:

      Patients have the right to determine what happens to their own bodies, and for consent to be valid, certain criteria must be met. These criteria include the person being informed about the intervention, having the capacity to consent, and giving consent voluntarily and freely without any pressure or undue influence.

      In order for a person to be deemed to have capacity to make a decision on a medical intervention, they must be able to understand the decision and the information provided, retain that information, weigh up the pros and cons, and communicate their decision.

      Valid consent can only be provided by adults, either by the patient themselves, a person authorized under a Lasting Power of Attorney, or someone with the authority to make treatment decisions, such as a court-appointed deputy or a guardian with welfare powers.

      In the UK, patients aged 16 and over are assumed to have the capacity to consent. If a patient is under 18 and appears to lack capacity, parental consent may be accepted. However, a young person of any age may consent to treatment if they are considered competent to make the decision, known as Gillick competence. Parental consent may also be given by those with parental responsibility.

      The Fraser guidelines apply to the prescription of contraception to under 16’s without parental involvement. These guidelines allow doctors to provide contraceptive advice and treatment without parental consent if certain criteria are met, including the young person understanding the advice, being unable to be persuaded to inform their parents, and their best interests requiring them to receive contraceptive advice or treatment.

      Competent adults have the right to refuse consent, even if it is deemed unwise or likely to result in harm. However, there are exceptions to this, such as compulsory treatment authorized by the mental health act or if the patient is under 18 and refusing treatment would put their health at serious risk.

      In emergency situations where a patient is unable to give consent, treatment may be provided without consent if it is immediately necessary to save their life or prevent a serious deterioration of their condition. Any treatment decision made without consent must be in the patient’s best interests, and if a decision is time-critical and the patient is unlikely to regain capacity in time, a best interest decision should be made. The treatment provided should be the least restrictive on the patient’s future choices.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      28.4
      Seconds
  • Question 4 - You are part of the team performing CPR on a child who has...

    Correct

    • You are part of the team performing CPR on a child who has gone into cardiac arrest. A healthcare assistant (HCA) takes over chest compressions from the charge nurse. You are concerned about the rate and depth of the compressions being given. You provide guidance to the HCA on the appropriate frequency and depth of chest compressions. What is the correct rate and depth of chest compression during CPR for a child?

      Your Answer: 100-120 compressions per minute to a depth of 5-6 cm

      Explanation:

      For adults, it is recommended to perform chest compressions at a rate of 100-120 compressions per minute. The depth of the compressions should be at least 5-6 cm.

      Further Reading:

      In the event of an adult experiencing cardiorespiratory arrest, it is crucial for doctors to be familiar with the Advanced Life Support (ALS) algorithm. They should also be knowledgeable about the proper technique for chest compressions, the appropriate rhythms for defibrillation, the reversible causes of arrest, and the drugs used in advanced life support.

      During chest compressions, the rate should be between 100-120 compressions per minute, with a depth of compression of 5-6 cm. The ratio of chest compressions to rescue breaths should be 30:2. It is important to change the person giving compressions regularly to prevent fatigue.

      There are two shockable ECG rhythms that doctors should be aware of: ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). These rhythms require defibrillation.

      There are four reversible causes of cardiorespiratory arrest, known as the 4 H’s and 4 T’s. The 4 H’s include hypoxia, hypovolemia, hypo or hyperkalemia or metabolic abnormalities, and hypothermia. The 4 T’s include thrombosis (coronary or pulmonary), tension pneumothorax, tamponade, and toxins. Identifying and treating these reversible causes is crucial for successful resuscitation.

      When it comes to resus drugs, they are considered of secondary importance during CPR due to the lack of high-quality evidence for their efficacy. However, adrenaline (epinephrine) and amiodarone are the two drugs included in the ALS algorithm. Doctors should be familiar with the dosing, route, and timing of administration for both drugs.

      Adrenaline should be administered intravenously at a concentration of 1 in 10,000 (100 micrograms/mL). It should be repeated every 3-5 minutes. Amiodarone is initially given at a dose of 300 mg, either from a pre-filled syringe or diluted in 20 mL of Glucose 5%. If required, an additional dose of 150 mg can be given by intravenous injection. This is followed by an intravenous infusion of 900 mg over 24 hours. The first dose of amiodarone is given after 3 shocks.

    • This question is part of the following fields:

      • Resus
      24.5
      Seconds
  • Question 5 - A 65-year-old patient presents with nausea and vomiting and decreased urine output. He...

    Correct

    • A 65-year-old patient presents with nausea and vomiting and decreased urine output. He has only passed a small amount of urine in the last day, and he has noticeable swelling in his ankles. His blood tests show a sudden increase in his creatinine levels in the last 48 hours, leading to a diagnosis of acute kidney injury (AKI).
      What is a potential cause of post-renal AKI?

      Your Answer: Papillary necrosis

      Explanation:

      Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This results in the accumulation of urea and other waste products in the body and disrupts the balance of fluids and electrolytes. AKI can occur in individuals with previously normal kidney function or those with pre-existing kidney disease, known as acute-on-chronic kidney disease. It is a relatively common condition, with approximately 15% of adults admitted to hospitals in the UK developing AKI.

      The causes of AKI can be categorized into pre-renal, intrinsic renal, and post-renal factors. The majority of AKI cases that develop outside of healthcare settings are due to pre-renal causes, accounting for 90% of cases. These causes typically involve low blood pressure associated with conditions like sepsis and fluid depletion. Medications, particularly ACE inhibitors and NSAIDs, are also frequently implicated.

      Pre-renal:
      – Volume depletion (e.g., severe bleeding, excessive vomiting or diarrhea, burns)
      – Oedematous states (e.g., heart failure, liver cirrhosis, nephrotic syndrome)
      – Low blood pressure (e.g., cardiogenic shock, sepsis, anaphylaxis)
      – Cardiovascular conditions (e.g., severe heart failure, arrhythmias)
      – Renal hypoperfusion: NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, abdominal aortic aneurysm
      – Renal artery stenosis
      – Hepatorenal syndrome

      Intrinsic renal:
      – Glomerular diseases (e.g., glomerulonephritis, thrombosis, hemolytic-uremic syndrome)
      – Tubular injury: acute tubular necrosis (ATN) following prolonged lack of blood supply
      – Acute interstitial nephritis due to drugs (e.g., NSAIDs), infection, or autoimmune diseases
      – Vascular diseases (e.g., vasculitis, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal vein thrombosis, malignant hypertension)
      – Eclampsia

      Post-renal:
      – Kidney stones
      – Blood clot
      – Papillary necrosis
      – Urethral stricture
      – Prostatic hypertrophy or malignancy
      – Bladder tumor
      – Radiation fibrosis
      – Pelvic malignancy
      – Retroperitoneal

    • This question is part of the following fields:

      • Nephrology
      25.4
      Seconds
  • Question 6 - A 3-year-old boy comes in with a high temperature and urine that has...

    Correct

    • A 3-year-old boy comes in with a high temperature and urine that has a strong odor. His mother is worried that he might have a urinary tract infection.
      According to NICE, which of the following symptoms is indicative of a UTI in this age group?

      Your Answer: Poor feeding

      Explanation:

      According to NICE, the presence of certain clinical features in a child between three months and five years old may indicate a urinary tract infection (UTI). These features include vomiting, poor feeding, lethargy, irritability, abdominal pain or tenderness, and urinary frequency or dysuria. For more information on this topic, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Urology
      23.6
      Seconds
  • Question 7 - A child who has been involved in a car accident undergoes a traumatic...

    Correct

    • A child who has been involved in a car accident undergoes a traumatic cardiac arrest. You perform an anterolateral thoracotomy.
      What is the accurate anatomical location for the incision that needs to be made?

      Your Answer: 4th intercostal space from the sternum to the posterior axillary line

      Explanation:

      An anterolateral thoracotomy is a surgical procedure performed on the front part of the chest wall. It is commonly used in Emergency Department thoracotomy, with a preference for a left-sided approach in patients with traumatic arrest or left-sided chest injuries. However, in patients with right-sided chest injuries and profound hypotension but have not arrested, a right-sided approach is recommended.

      The procedure is carried out in the following steps:
      – An incision is made along the 4th or 5th intercostal space, starting from the sternum at the front and extending to the posterior axillary line.
      – The incision should be deep enough to partially cut through the latissimus dorsi muscle.
      – The skin, subcutaneous fat, and superficial portions of the pectoralis and serratus muscles are divided.
      – The parietal pleura is divided, allowing entry into the pleural cavity.
      – The intercostal muscles are completely cut, and a rib spreader is placed and opened to provide visualization of the thoracic cavity.
      – The anterolateral approach allows access to important anatomical structures during resuscitation, including the pulmonary hilum, heart, and aorta.

      In cases where there is suspicion of a right-sided heart injury, an additional incision can be made on the right side, extending across the entire chest. This is known as a bilateral anterolateral thoracotomy or a clamshell thoracotomy.

    • This question is part of the following fields:

      • Trauma
      23.9
      Seconds
  • Question 8 - A 60-year-old individual presents with an arthropathy affecting the metatarsophalangeal joint on their...

    Correct

    • A 60-year-old individual presents with an arthropathy affecting the metatarsophalangeal joint on their left foot. Gout is suspected, and a joint aspirate is sent to the lab for analysis.
      What type of crystals are deposited in the joints during gout?

      Your Answer: Urate crystals

      Explanation:

      Gout and pseudogout are both characterized by the presence of crystal deposits in the joints that are affected. Gout occurs when urate crystals are deposited, while pseudogout occurs when calcium pyrophosphate crystals are deposited. Under a microscope, these crystals can be distinguished by their appearance. Urate crystals are needle-shaped and negatively birefringent, while calcium pyrophosphate crystals are brick-shaped and positively birefringent.

      Gout can affect any joint in the body, but it most commonly manifests in the hallux metatarsophalangeal joint, which is the joint at the base of the big toe. This joint is affected in approximately 50% of gout cases. On the other hand, pseudogout primarily affects the larger joints, such as the knee.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      15.7
      Seconds
  • Question 9 - You review a child with a history of autism who is currently experiencing...

    Incorrect

    • You review a child with a history of autism who is currently experiencing severe communication difficulties. You attempt to engage in conversation with the child but find it challenging to comprehend their speech. Their language lacks coherence and seems to consist of random words and phrases.
      Which ONE of the following communication disorders is the child displaying?

      Your Answer: Gedankenlautwerden

      Correct Answer: Word salad

      Explanation:

      A word salad refers to a jumbled or incomprehensible combination of seemingly arbitrary words and phrases. This phenomenon is frequently observed in individuals with schizophrenia and dementia.

    • This question is part of the following fields:

      • Mental Health
      18.3
      Seconds
  • Question 10 - A 3-year-old toddler is brought to the Emergency Department after ingesting a few...

    Correct

    • A 3-year-old toddler is brought to the Emergency Department after ingesting a few of his mother's ibuprofen tablets 30 minutes ago. The child is currently showing no symptoms and is stable. The attending physician recommends giving a dose of activated charcoal. The child weighs 15 kg.
      What is the appropriate dosage of activated charcoal to administer in this case?

      Your Answer: 20 g orally

      Explanation:

      Activated charcoal is a commonly utilized substance for decontamination in cases of poisoning. Its main function is to attract and bind molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. This powder is created by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then concentrating it with a solution of zinc chloride. Through this process, the activated charcoal develops a complex network of pores, providing it with a large surface area of approximately 3,000 m2/g. This extensive surface area allows it to effectively hinder the absorption of the harmful toxin by up to 50%.

      The typical dosage for adults is 50 grams, while children are usually given 1 gram per kilogram of body weight. Activated charcoal can be administered orally or through a nasogastric tube. It is crucial to administer it within one hour of ingestion, and if necessary, a second dose may be repeated after one hour.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      56.3
      Seconds
  • Question 11 - A 35-year-old woman is given a medication during the advanced stages of pregnancy....

    Correct

    • A 35-year-old woman is given a medication during the advanced stages of pregnancy. As a result, the newborn experiences respiratory depression and develops a neonatal withdrawal syndrome.

      Which of the following medications is the most probable cause of these abnormalities?

      Your Answer: Diazepam

      Explanation:

      During the later stages of pregnancy, the use of diazepam has been linked to respiratory depression in newborns and a withdrawal syndrome. There are several drugs that can have adverse effects during pregnancy, and the list below outlines the most commonly encountered ones.

      ACE inhibitors, such as ramipril, can cause hypoperfusion, renal failure, and the oligohydramnios sequence if given in the second and third trimesters. Aminoglycosides, like gentamicin, can lead to ototoxicity and deafness. High doses of aspirin can result in first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g., 75 mg) do not pose significant risks.

      Benzodiazepines, including diazepam, can cause respiratory depression and a neonatal withdrawal syndrome when administered late in pregnancy. Calcium-channel blockers can cause phalangeal abnormalities if given in the first trimester and fetal growth retardation if given in the second and third trimesters. Carbamazepine can lead to hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol is associated with grey baby syndrome. Corticosteroids, if given in the first trimester, may cause orofacial clefts. Danazol, when administered in the first trimester, can cause masculinization of the female fetuses genitals. Pregnant women should avoid handling crushed or broken tablets of finasteride as it can affect male sex organ development.

      Haloperidol, if given in the first trimester, may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate. Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability.

      Lithium, if given in the first trimester, poses a risk of fetal cardiac malformations. In the second and third trimesters, it can result in hypotonia, lethargy, feeding problems, hypothyroidism, goiter, and nephrogenic diabetes insipidus in the neonate.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      14.3
      Seconds
  • Question 12 - A 60-year-old woman comes in with a nosebleed that began after blowing her...

    Correct

    • A 60-year-old woman comes in with a nosebleed that began after blowing her nose an hour ago. You assessed her when she arrived 30 minutes ago and recommended that she try to stop the bleeding by pinching the soft, cartilaginous part of her nose. She has been doing this since then, but her nose is still bleeding. During the examination, you can see bleeding points in both nostrils. What is the most suitable next step to take?

      Your Answer: Pack the nose with nasal tampons, e.g. Rapid Rhinos

      Explanation:

      When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.

      Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.

      First aid measures to control bleeding include the following steps:
      1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
      2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
      3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
      4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
      5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.

      If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      29.4
      Seconds
  • Question 13 - You evaluate a 65-year-old woman with a diagnosis of chronic lymphocytic leukemia (CLL)....

    Correct

    • You evaluate a 65-year-old woman with a diagnosis of chronic lymphocytic leukemia (CLL).
      What is the PRIMARY factor that contributes to the immunodeficiency observed in this condition?

      Your Answer: Hypogammaglobulinemia

      Explanation:

      All individuals diagnosed with chronic lymphocytic leukaemia (CLL) experience some level of weakened immune system, although for many, it is not severe enough to have a significant impact on their health. Infections are the leading cause of death for 25-50% of CLL patients, with respiratory tract, skin, and urinary tract bacterial infections being the most prevalent. The primary factor contributing to the weakened immune system in CLL patients is hypogammaglobulinaemia, which is present in approximately 85% of all individuals with this condition.

    • This question is part of the following fields:

      • Haematology
      24.3
      Seconds
  • Question 14 - A 40-year-old woman presents with a painful, swollen right ankle following a recent...

    Incorrect

    • A 40-year-old woman presents with a painful, swollen right ankle following a recent hike in the mountains. You assess her for a possible sprained ankle.
      At which of the following locations do the NICE guidelines recommend that you measure the ankle circumference?

      Your Answer: 10 cm above the lateral malleolus

      Correct Answer: 10 cm below the tibial tuberosity

      Explanation:

      The NICE guidelines for suspected deep vein thrombosis (DVT) suggest considering the possibility of DVT if typical symptoms and signs are present, particularly if the person has risk factors like previous venous thromboembolism and immobility.

      Typical signs and symptoms of DVT include unilateral localized pain (often throbbing) that occurs during walking or bearing weight, as well as calf swelling (or, less commonly, swelling of the entire leg). Other signs to look out for are tenderness, skin changes such as edema, redness, and warmth, and vein distension.

      To rule out other potential causes for the symptoms and signs, it is important to conduct a physical examination and review the person’s general medical history.

      When assessing leg and thigh swelling, it is recommended to measure the circumference of the leg 10 cm below the tibial tuberosity and compare it with the unaffected leg. A difference of more than 3 cm between the two legs increases the likelihood of DVT.

      Additionally, it is important to check for edema and dilated collateral superficial veins on the affected side.

      To assess the likelihood of DVT and guide further management, the two-level DVT Wells score can be used.

      For more information, you can refer to the NICE Clinical Knowledge Summary on deep vein thrombosis.

    • This question is part of the following fields:

      • Vascular
      23.2
      Seconds
  • Question 15 - A 21 year old female is brought to the emergency department by her...

    Correct

    • A 21 year old female is brought to the emergency department by her boyfriend as he is concerned the patient has become drowsy after intermittent vomiting throughout the day. The boyfriend informs you that the patient is a type 1 diabetic. After evaluation, the patient is diagnosed with diabetic ketoacidosis and started on fluids and an insulin infusion. Due to a lack of available beds, the patient is transferred to the A&E observation ward. Several hours later, you are asked about discontinuing the insulin infusion. What criteria must be met before stopping the insulin infusion?

      Your Answer: Ketones less than 0.3 mmol/l and venous pH over 7.3

      Explanation:

      In the treatment of diabetic ketoacidosis (DKA), it is important to continue the infusion of insulin until certain criteria are met. These criteria include ketone levels being less than 0.3 mmol/L and the pH of the blood being above 7.3 or the bicarbonate levels being above 18 mmol/L. Additionally, the patient should feel comfortable enough to eat at this point. It is crucial not to stop the intravenous insulin infusion until at least 30 minutes after administering subcutaneous short-acting insulin.

      Further Reading:

      Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.

      The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.

      DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.

      The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.

      Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.

      Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.

    • This question is part of the following fields:

      • Endocrinology
      39.7
      Seconds
  • Question 16 - A 35-year-old woman is given chloramphenicol for an infection while she is pregnant....

    Correct

    • A 35-year-old woman is given chloramphenicol for an infection while she is pregnant. As a result of this treatment, the newborn develops a deformity.
      Which of the following deformities is most likely to occur as a result of using this medication during pregnancy?

      Your Answer: Grey baby syndrome

      Explanation:

      Grey baby syndrome is a rare but serious side effect that can occur in neonates, especially premature babies, as a result of the build-up of the antibiotic chloramphenicol. This condition is characterized by several symptoms, including ashen grey skin color, poor feeding, vomiting, cyanosis, hypotension, hypothermia, hypotonia, cardiovascular collapse, abdominal distension, and respiratory difficulties.

      During pregnancy, there are several drugs that can have adverse effects on the developing fetus. ACE inhibitors, such as ramipril, if given in the second and third trimesters, can lead to hypoperfusion, renal failure, and the oligohydramnios sequence. Aminoglycosides, like gentamicin, can cause ototoxicity and deafness. High doses of aspirin can result in first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses of aspirin (e.g., 75 mg) do not pose significant risks.

      Benzodiazepines, such as diazepam, when administered late in pregnancy, can cause respiratory depression and a neonatal withdrawal syndrome. Calcium-channel blockers, if given in the first trimester, may lead to phalangeal abnormalities, while their use in the second and third trimesters can result in fetal growth retardation. Carbamazepine can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol, as mentioned earlier, can cause grey baby syndrome. Corticosteroids, if given in the first trimester, may cause orofacial clefts. Danazol, if administered in the first trimester, can cause masculinization of the female fetuses genitals. Pregnant women should avoid handling crushed or broken tablets of finasteride, as it can be absorbed through the skin and affect male sex organ development.

      Haloperidol, if given in the first trimester, may cause limb malformations, while its use in the third trimester increases the risk of extrapyramidal symptoms in the neonate. Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      9.6
      Seconds
  • Question 17 - You assess a patient with nausea, vomiting, restlessness, and palpitations. She is on...

    Correct

    • You assess a patient with nausea, vomiting, restlessness, and palpitations. She is on theophylline for the treatment of her COPD. You suspect toxicity and order blood tests for evaluation.
      What is the target range for theophylline levels?

      Your Answer: 10-20 mg/L

      Explanation:

      The therapeutic range for theophylline is quite limited, ranging from 10 to 20 micrograms per milliliter (10-20 mg/L). It is important to estimate the plasma concentration of aminophylline during long-term treatment as it can provide valuable information.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      24.8
      Seconds
  • Question 18 - A 35-year-old businessman has returned from a trip to the U.S.A. this morning...

    Correct

    • A 35-year-old businessman has returned from a trip to the U.S.A. this morning with ear pain and ringing in his ears. He reports experiencing significant pain in his right ear while the plane was descending. He also feels slightly dizzy. Upon examination, there is fluid buildup behind his eardrum and Weber's test shows lateralization to the right side.

      What is the MOST SUITABLE next step in managing this patient?

      Your Answer: Give patient advice and reassurance

      Explanation:

      This patient has experienced otic barotrauma, which is most commonly seen during aircraft descent but can also occur in divers. Otic barotrauma occurs when the eustachian tube fails to equalize the pressure between the middle ear and the atmosphere, resulting in a pressure difference. This is more likely to happen in patients with eustachian tube dysfunction, such as those with acute otitis media or glue ear.

      Patients with otic barotrauma often complain of severe ear pain, conductive hearing loss, ringing in the ears (tinnitus), and dizziness (vertigo). Upon examination, fluid can be observed behind the eardrum, and in more severe cases, the eardrum may even rupture.

      In most instances, the symptoms of otic barotrauma resolve within a few days without any treatment. However, in more severe cases, it may take 2-3 weeks for the symptoms to subside. Nasal decongestants can be beneficial before and during a flight, but their effectiveness is limited once symptoms have already developed. Nasal steroids have no role in the management of otic barotrauma, and antibiotics should only be used if an infection develops.

      The most appropriate course of action in this case would be to provide the patient with an explanation of what has occurred and reassure them that their symptoms should improve soon.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      35.2
      Seconds
  • Question 19 - You evaluate a 25-year-old woman who is worried about her weight. She has...

    Correct

    • You evaluate a 25-year-old woman who is worried about her weight. She has been attempting without success to shed pounds for the past year and believes her cravings are to blame. She has a previous medical history of depression and self-harm, which is managed with sertraline. During the examination, her body mass index is measured at 22, and you observe calluses on her knuckles. Additionally, there are multiple healed linear scars present on both forearms.

      What is the most probable diagnosis in this case?

      Your Answer: Bulimia nervosa

      Explanation:

      Bulimia nervosa is an eating disorder characterized by episodes of binge eating followed by purging. Unlike anorexia nervosa, most individuals with bulimia nervosa have a normal body mass index. The clinical features of bulimia nervosa include binge eating, vomiting after binge episodes, a preoccupation with weight and body image, an obsession with eating, an irresistible craving for food, periods of starvation, and the misuse of diuretics, laxatives, and thyroid hormones. Often, patients may develop calluses on their knuckles from scraping against their teeth while inducing vomiting. Repeated episodes of vomiting can also lead to dental enamel erosion. Additionally, there is a strong correlation between bulimia nervosa and depression as well as deliberate self-harm.

    • This question is part of the following fields:

      • Mental Health
      17.8
      Seconds
  • Question 20 - A 25-year-old engineering student returns from a hiking trip in South America with...

    Incorrect

    • A 25-year-old engineering student returns from a hiking trip in South America with a high temperature, body aches, and shivering. After further examination, they are diagnosed with Plasmodium falciparum malaria.
      Which of the following statements about Plasmodium falciparum malaria is NOT true?

      Your Answer: The incubation period is 7-14 days

      Correct Answer: It is commonly the result of travel in the Indian subcontinent

      Explanation:

      Plasmodium falciparum malaria is transmitted by female mosquitoes of the Anopheles genus. While it can be found worldwide, it is most prevalent in Africa. The incubation period for this type of malaria is typically between 7 to 14 days.

      The parasite, known as sporozoites, invades hepatocytes (liver cells). Inside the hepatocyte, the parasite undergoes asexual reproduction, resulting in the production of merozoites. These merozoites are then released into the bloodstream and invade the red blood cells of the host.

      Currently, the recommended treatment for P. falciparum malaria is artemisinin-based combination therapy (ACT). This involves combining fast-acting artemisinin-based compounds with drugs from different classes. Some of the companion drugs used in ACT include lumefantrine, mefloquine, amodiaquine, sulfadoxine/pyrimethamine, piperaquine, and chlorproguanil/dapsone. Artemisinin derivatives such as dihydroartemisinin, artesunate, and artemether are also used.

      In cases where artemisinin combination therapy is not available, oral quinine or atovaquone with proguanil hydrochloride can be used as alternatives. However, quinine is not well-tolerated for prolonged treatment and should be combined with another drug, typically oral doxycycline (or clindamycin for pregnant women and young children).

      For severe or complicated cases of falciparum malaria, it is recommended to manage the patient in a high dependency unit or intensive care setting. Intravenous artesunate is indicated for all patients with severe or complicated falciparum malaria, as well as those at high risk of developing severe disease (e.g., if more than 2% of red blood cells are parasitized) or if the patient is unable to take oral treatment. After a minimum of 24 hours of intravenous artesunate treatment and once the patient has shown improvement and can tolerate oral treatment, a full course of artemisinin combination therapy should be administered.

    • This question is part of the following fields:

      • Infectious Diseases
      43.6
      Seconds
  • Question 21 - A child with a known adrenal insufficiency presents with vomiting, excessive sweating, and...

    Incorrect

    • A child with a known adrenal insufficiency presents with vomiting, excessive sweating, and abdominal discomfort. You suspect the possibility of an Addisonian crisis.
      What type of acid-base imbalance would you anticipate in a patient with adrenal insufficiency?

      Your Answer: Metabolic alkalosis

      Correct Answer: Normal anion gap metabolic acidosis

      Explanation:

      The following provides a summary of common causes for different acid-base disorders.

      Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.

      Respiratory acidosis, on the other hand, is often associated with chronic obstructive pulmonary disease (COPD), life-threatening asthma, pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.

      Metabolic alkalosis can occur due to vomiting, potassium depletion (often caused by diuretic usage), Cushing’s syndrome, or Conn’s syndrome.

      Metabolic acidosis with a raised anion gap can be caused by lactic acidosis (such as in cases of hypoxemia, shock, sepsis, or infarction), ketoacidosis (such as in diabetes, starvation, or alcohol excess), renal failure, or poisoning (such as in late stages of aspirin overdose, methanol or ethylene glycol ingestion).

      Lastly, metabolic acidosis with a normal anion gap can be a result of conditions like diarrhea, ammonium chloride ingestion, or adrenal insufficiency.

    • This question is part of the following fields:

      • Endocrinology
      21
      Seconds
  • Question 22 - A 65-year-old man is brought in to see you by his wife. She...

    Correct

    • A 65-year-old man is brought in to see you by his wife. She is concerned that he may have had a 'mini-stroke.' After conducting a comprehensive history and examination, you conclude that it is highly probable that he has experienced a transient ischemic attack (TIA). You decide to refer him to the nearby specialist TIA clinic.
      What imaging procedure is most likely to be arranged at the TIA clinic?

      Your Answer: Carotid imaging

      Explanation:

      The NICE recommendations for managing patients with suspected TIA are as follows:

      – Offer aspirin (300 mg daily) to individuals who have experienced a suspected TIA, unless there are contraindications. This treatment should be started immediately.
      – Immediately refer individuals who have had a suspected TIA for specialist assessment and investigation. They should be seen within 24 hours of the onset of symptoms.
      – Avoid using scoring systems, such as ABCD2, to assess the risk of subsequent stroke or determine the urgency of referral for individuals with suspected or confirmed TIA.
      – Provide secondary prevention measures, in addition to aspirin, as soon as possible after confirming the diagnosis of TIA.

      The NICE recommendations for imaging in individuals with suspected TIA or acute non-disabling stroke are as follows:

      – Do not offer CT brain scanning to individuals with suspected TIA, unless there is clinical suspicion of an alternative diagnosis that CT could detect.
      – After a specialist assessment in the TIA clinic, consider performing an MRI (including diffusion-weighted and blood-sensitive sequences) to determine the area of ischemia, detect hemorrhage, or identify alternative pathologies. If an MRI is conducted, it should be done on the same day as the assessment.
      – Carotid imaging is necessary for all individuals with TIA who, after specialist assessment, are considered candidates for carotid endarterectomy. This imaging should be done urgently.

      For more information, refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old: diagnosis and initial management.

    • This question is part of the following fields:

      • Neurology
      24.7
      Seconds
  • Question 23 - A 25-year-old woman arrives at the Emergency Department after ingesting an overdose 30...

    Correct

    • A 25-year-old woman arrives at the Emergency Department after ingesting an overdose 30 minutes ago. She is currently showing no symptoms and her vital signs are stable. The attending physician recommends administering a dose of activated charcoal.
      Which of the following substances or toxins is activated charcoal NOT effective in decontaminating?

      Your Answer: Lithium

      Explanation:

      Activated charcoal is a commonly used substance for decontamination in cases of poisoning. Its main function is to adsorb the molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. It is produced by subjecting carbonaceous matter to high temperatures, a process known as pyrolysis, and then concentrating it with a zinc chloride solution. This creates a network of pores within the charcoal, giving it a large absorptive area of approximately 3,000 m2/g. This porous structure helps prevent the absorption of the harmful toxin by up to 50%.

      The usual dosage of activated charcoal is 50 grams for adults and 1 gram per kilogram of body weight for children. It can be administered orally or through a nasogastric tube. It is important to give the charcoal within one hour of ingestion, and it may be repeated after one hour if necessary.

      However, there are certain situations where activated charcoal should not be used. If the patient is unconscious or in a coma, there is a risk of aspiration, so the charcoal should not be given. Similarly, if seizures are likely to occur, there is a risk of aspiration and the charcoal should be avoided. Additionally, if there is reduced gastrointestinal motility, there is a risk of obstruction, so activated charcoal should not be used in such cases.

      Activated charcoal is effective in treating overdose with various drugs and toxins, including aspirin, paracetamol, barbiturates, tricyclic antidepressants, digoxin, amphetamines, morphine, cocaine, and phenothiazines. However, it is ineffective in treating overdose with substances such as iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon, strong acids, or alkalis.

      There are some potential adverse effects associated with activated charcoal. These include nausea and vomiting, diarrhea, constipation, bezoar formation (a mass of undigested material that can cause blockages), bowel obstruction, pulmonary aspiration (inhaling the charcoal into the lungs), and impaired absorption of oral medications or antidotes.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      13.6
      Seconds
  • Question 24 - A 68-year-old woman, who has been smoking for her entire life, is diagnosed...

    Correct

    • A 68-year-old woman, who has been smoking for her entire life, is diagnosed with a small cell carcinoma of the lung. After further examination, it is revealed that she has developed the syndrome of inappropriate ADH secretion (SIADH) as a result of this.
      What kind of electrolyte disturbance would you anticipate in this case?

      Your Answer: Low serum Na, low serum osmolarity, high urine osmolarity

      Explanation:

      Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by the excessive and uncontrollable release of antidiuretic hormone (ADH). This can occur either from the posterior pituitary gland or from an abnormal non-pituitary source. There are various conditions that can disrupt the regulation of ADH secretion in the central nervous system and lead to SIADH. These include CNS damage such as meningitis or subarachnoid hemorrhage, paraneoplastic syndromes like small cell carcinoma of the lung, infections such as atypical pneumonia or cerebral abscess, and certain drugs like carbamazepine, TCAs, and SSRIs.

      The typical biochemical profile observed in SIADH is characterized by low levels of serum sodium (usually less than 135 mmol/l), low serum osmolality, and high urine osmolality.

    • This question is part of the following fields:

      • Oncological Emergencies
      34.2
      Seconds
  • Question 25 - A 35-year-old woman is brought into the emergency department after being hit by...

    Correct

    • A 35-year-old woman is brought into the emergency department after being hit by a car while riding her bike. The patient was not wearing a helmet and suffered a head injury from hitting the pavement. She has a significant scalp contusion and appears drowsy. There is a suspicion of increased intracranial pressure. How does intracranial pressure affect cerebral perfusion pressure?

      Your Answer: Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - intracranial pressure (ICP)

      Explanation:

      Cerebral perfusion pressure (CPP) is calculated by adding the intracranial pressure (ICP) to the diastolic blood pressure (DBP).

      Further Reading:

      Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.

      The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.

      There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.

    • This question is part of the following fields:

      • Neurology
      52.2
      Seconds
  • Question 26 - A 25-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic...

    Correct

    • A 25-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic chest pain. She has recently returned from a vacation in Brazil. Her vital signs are as follows: temperature 38.2°C, oxygen saturation 93% on room air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, she has a tender, swollen left calf. Her chest X-ray shows no apparent abnormalities.
      Which of the following tests should be ordered?

      Your Answer: Doppler ultrasound scan of leg

      Explanation:

      Based on the clinical history and examination, it strongly indicates that the patient may have a pulmonary embolism caused by a deep vein thrombosis in his right leg. To confirm this, it is recommended that he undergoes a CT pulmonary angiogram and doppler ultrasound scan of his right leg.

      The typical symptoms of a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. Additionally, there may be symptoms suggesting the presence of a deep vein thrombosis. Other signs to look out for are rapid breathing and heart rate, fever, and in severe cases, signs of systemic shock, a gallop heart rhythm, and increased jugular venous pressure.

    • This question is part of the following fields:

      • Respiratory
      27.6
      Seconds
  • Question 27 - A 65-year-old woman comes to the clinic after a fall. You observe that...

    Correct

    • A 65-year-old woman comes to the clinic after a fall. You observe that she has a tremor in her left hand that is most noticeable when she is sitting and at rest. Additionally, you notice that it took her quite a while to walk towards you and unbutton her coat before sitting down. When you shake her hand, you notice that her left forearm feels stiff.
      What is the SINGLE most probable diagnosis?

      Your Answer: Parkinson’s disease

      Explanation:

      Parkinson’s disease (PD) is a progressive neurodegenerative condition that occurs when the dopamine-containing cells in the substantia nigra die. It is estimated that PD affects around 100-180 individuals per 100,000 of the population, which translates to approximately 6-11 people per 6,000 individuals in the general population of the UK. The annual incidence of PD is between 4-20 cases per 100,000 people. The prevalence of PD increases with age, with approximately 0.5% of individuals aged 65 to 74 being affected and 1-2% of individuals aged 75 and older. Additionally, PD is more prevalent and has a higher incidence in males.

      The classic clinical features of Parkinson’s disease include hypokinesia, which refers to a poverty of movement, and bradykinesia, which is characterized by slowness of movement. Rest tremor, typically occurring at a rate of 4-6 cycles per second, is also commonly observed in PD patients. Another clinical feature is rigidity, which is characterized by increased muscle tone and a phenomenon known as cogwheel rigidity.

    • This question is part of the following fields:

      • Neurology
      14.1
      Seconds
  • Question 28 - A 45-year-old man presents with palpitations and is found to have atrial fibrillation....

    Correct

    • A 45-year-old man presents with palpitations and is found to have atrial fibrillation. You are requested to evaluate his ECG.
      Which of the following statements is NOT true regarding the ECG in atrial fibrillation?

      Your Answer: Ashman beats have a poor prognosis

      Explanation:

      The classic ECG features of atrial fibrillation include an irregularly irregular rhythm, the absence of p-waves, an irregular ventricular rate, and the presence of fibrillation waves. This irregular rhythm occurs because the atrial impulses are filtered out by the AV node.

      In addition, Ashman beats may be observed in atrial fibrillation. These beats are characterized by wide complex QRS complexes, often with a morphology resembling right bundle branch block. They occur after a short R-R interval that is preceded by a prolonged R-R interval. Fortunately, Ashman beats are generally considered harmless.

      The disorganized electrical activity in atrial fibrillation typically originates at the root of the pulmonary veins.

    • This question is part of the following fields:

      • Cardiology
      17.1
      Seconds
  • Question 29 - You are requested to evaluate a 32-year-old male patient who has undergone an...

    Correct

    • You are requested to evaluate a 32-year-old male patient who has undergone an initial evaluation by one of the medical students. The medical student suspects that the patient may have irritable bowel syndrome (IBS). Which of the subsequent clinical characteristics is atypical for IBS and would raise concerns about a potentially more severe underlying condition in this patient?

      Your Answer: Rectal bleeding

      Explanation:

      If someone with IBS experiences unintentional weight loss or rectal bleeding, it is important to investigate further as these symptoms are not typical of IBS and may indicate a more serious underlying condition. Other alarm symptoms to watch out for include positive faecal immunochemical test (FIT), change in bowel habit after the age of 60, elevated faecal calprotectin levels, iron deficiency anaemia, persistent or frequent bloating in females (especially if over 50), the presence of an abdominal or rectal mass, or a family history of bowel cancer, ovarian cancer, coeliac disease, or inflammatory bowel disease.

      Further Reading:

      Irritable bowel syndrome (IBS) is a chronic disorder that affects the interaction between the gut and the brain. The exact cause of IBS is not fully understood, but factors such as genetics, drug use, enteric infections, diet, and psychosocial factors are believed to play a role. The main symptoms of IBS include abdominal pain, changes in stool form and/or frequency, and bloating. IBS can be classified into subtypes based on the predominant stool type, including diarrhea-predominant, constipation-predominant, mixed, and unclassified.

      Diagnosing IBS involves using the Rome IV criteria, which includes recurrent abdominal pain associated with changes in stool frequency and form. It is important to rule out other more serious conditions that may mimic IBS through a thorough history, physical examination, and appropriate investigations. Treatment for IBS primarily involves diet and lifestyle modifications. Patients are advised to eat regular meals with a healthy, balanced diet and adjust their fiber intake based on symptoms. A low FODMAP diet may be trialed, and a dietician may be consulted for guidance. Regular physical activity and weight management are also recommended.

      Psychosocial factors, such as stress, anxiety, and depression, should be addressed and managed appropriately. If constipation is a predominant symptom, soluble fiber supplements or foods high in soluble fiber may be recommended. Laxatives can be considered if constipation persists, and linaclotide may be tried if optimal doses of previous laxatives have not been effective. Antimotility drugs like loperamide can be used for diarrhea, and antispasmodic drugs or low-dose tricyclic antidepressants may be prescribed for abdominal pain. If symptoms persist or are refractory to treatment, alternative diagnoses should be considered, and referral to a specialist may be necessary.

      Overall, the management of IBS should be individualized based on the patient’s symptoms and psychosocial situation. Clear explanation of the condition and providing resources for patient education, such as the NHS patient information leaflet and support from organizations like The IBS Network, can also be beneficial.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      26.6
      Seconds
  • Question 30 - A 45-year-old man has been experiencing progressive weakness and numbness in his legs...

    Correct

    • A 45-year-old man has been experiencing progressive weakness and numbness in his legs for the past several days. Additionally, he has been feeling breathless during walking. He recently went on a vacation where he had diarrhea, and a stool culture confirmed an infection with Campylobacter jejuni.

      What is the SINGLE most probable diagnosis?

      Your Answer: Guillain-Barré syndrome

      Explanation:

      Guillain-Barré syndrome (GBS) affects approximately 1-2 individuals per 100,000 annually and is a condition that primarily affects the peripheral nervous system, including the autonomic system. The most common initial symptom is weakness in the hands or feet, often accompanied by pain and tingling sensations as the paralysis spreads. Miller Fisher syndrome, a variant of GBS, is characterized by a triad of symptoms: ataxia, areflexia, and ophthalmoplegia.

      Due to the potential serious consequences of autonomic involvement, such as fluctuations in blood pressure and cardiac arrhythmias, patients with GBS are typically hospitalized. As the diaphragm becomes paralyzed and swallowing becomes difficult, patients may require ventilation and nasogastric feeding.

      GBS is an autoimmune disease that usually develops within three weeks of an infection. The leading cause is Campylobacter jejuni, followed by Epstein-Barr virus, cytomegalovirus, and Mycoplasma pneumoniae. While the patient’s immune response effectively targets the initial infection, it also mistakenly attacks the host tissue.

      Symptoms of GBS typically peak around four weeks and then gradually improve. Diagnosis is based on clinical examination, which confirms the presence of areflexia and progressive weakness in the legs (and sometimes arms). Nerve conduction studies and lumbar puncture can also aid in diagnosis, with the latter often showing elevated protein levels and few white blood cells.

      Treatment for GBS is primarily supportive, with the use of immunoglobulins to shorten the duration of the illness being common. Plasma exchange may also be utilized, although it has become less common since the introduction of immunoglobulin therapy.

      Approximately 80% of patients with GBS make a full recovery, although this often requires a lengthy hospital stay. The mortality rate is around 5%, depending on the availability of necessary facilities such as ventilatory support during the acute phase. Additionally, about 15% of patients may experience some permanent disability, such as weakness or pain.

    • This question is part of the following fields:

      • Neurology
      23.7
      Seconds
  • Question 31 - You are a member of the trauma team and have been assigned the...

    Correct

    • You are a member of the trauma team and have been assigned the task of inserting an arterial line into the right radial artery. When inserting the radial artery line, what is the angle at which the catheter needle is initially advanced in relation to the skin?

      Your Answer: 30-45 degrees

      Explanation:

      The arterial line needle is inserted into the skin at an angle between 30 and 45 degrees. For a more detailed demonstration, please refer to the video provided in the media links section.

      Further Reading:

      Arterial line insertion is a procedure used to monitor arterial blood pressure continuously and obtain frequent blood gas samples. It is typically done when non-invasive blood pressure monitoring is not possible or when there is an anticipation of hemodynamic instability. The most common site for arterial line insertion is the radial artery, although other sites such as the ulnar, brachial, axillary, posterior tibial, femoral, and dorsalis pedis arteries can also be used.

      The radial artery is preferred for arterial line insertion due to its superficial location, ease of identification and access, and lower complication rate compared to other sites. Before inserting the arterial line, it is important to perform Allen’s test to check for collateral circulation to the hand.

      The procedure begins by identifying the artery by palpating the pulse at the wrist and confirming its position with doppler ultrasound if necessary. The wrist is then positioned dorsiflexed, and the skin is prepared and aseptic technique is maintained throughout the procedure. Local anesthesia is infiltrated at the insertion site, and the catheter needle is inserted at an angle of 30-45 degrees to the skin. Once flashback of pulsatile blood is seen, the catheter angle is flattened and advanced a few millimeters into the artery. Alternatively, a guide wire can be used with an over the wire technique.

      After the catheter is advanced, the needle is withdrawn, and the catheter is connected to the transducer system and secured in place with sutures. It is important to be aware of absolute and relative contraindications to arterial line placement, as well as potential complications such as infection, thrombosis, hemorrhage, emboli, pseudo-aneurysm formation, AV fistula formation, arterial dissection, and nerve injury/compression.

      Overall, arterial line insertion is a valuable procedure for continuous arterial blood pressure monitoring and frequent blood gas sampling, and the radial artery is the most commonly used site due to its accessibility and lower complication rate.

    • This question is part of the following fields:

      • Resus
      25.3
      Seconds
  • Question 32 - A 35-year-old woman comes in with sharp pain while having a bowel movement....

    Correct

    • A 35-year-old woman comes in with sharp pain while having a bowel movement. The pain usually continues for an additional 30-60 minutes afterward. She has also observed small amounts of bright red blood on the toilet paper when wiping. She has been experiencing constipation for the past couple of weeks.

      What is the SINGLE most probable diagnosis?

      Your Answer: Anal fissure

      Explanation:

      An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline, and they are often caused by the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.

      Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last for up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.

      The initial management approach for an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)

      Sphincterotomy, a surgical procedure, should be reserved for cases where the fissure does not heal with conservative measures. It has a success rate of 90%.

    • This question is part of the following fields:

      • Surgical Emergencies
      12.7
      Seconds
  • Question 33 - A 35 year old man presents to the emergency department complaining of worsening...

    Correct

    • A 35 year old man presents to the emergency department complaining of worsening difficulty breathing that has been developing over the last 2 days. His partner mentioned that he looked pale. He informs you that he usually doesn't take any medications but started taking chloroquine for malaria prevention 5 days ago as he is planning to travel to Kenya next week. His oxygen saturation is 89% on room air and you observe that he appears bluish in color. Upon obtaining a blood gas, you notice that his blood has a chocolate-like hue. What is the probable diagnosis?

      Your Answer: Methaemoglobinaemia

      Explanation:

      Methaemoglobinaemia is a condition characterized by various symptoms such as headache, anxiety, acidosis, arrhythmia, seizure activity, reduced consciousness or coma. One notable feature is the presence of brown or chocolate coloured blood. It is important to note that the patient is taking chloroquine, which is a known trigger for methaemoglobinaemia. Additionally, despite the condition, the patient’s arterial blood gas analysis shows a normal partial pressure of oxygen.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

    • This question is part of the following fields:

      • Haematology
      83.4
      Seconds
  • Question 34 - A 65 year old male comes to the emergency department with a 24...

    Correct

    • A 65 year old male comes to the emergency department with a 24 hour history of increasing dizziness. The patient reports feeling a sensation of spinning upon waking up this morning, and it has progressively worsened throughout the day. The patient mentions that head movements exacerbate the symptoms, but even when remaining still, the spinning sensation persists. There are no complaints of hearing loss, ringing in the ears, changes in vision, or focal neurological abnormalities.

      What is the most probable diagnosis?

      Your Answer: Vestibular neuronitis

      Explanation:

      Vestibular neuronitis is characterized by the sudden and prolonged onset of rotational vertigo. This vertigo can occur spontaneously, upon waking up, or gradually worsen throughout the day. It is particularly aggravated by changes in head position, although it remains constant even when the head is still. Unlike other conditions, vestibular neuronitis does not cause hearing loss, tinnitus, or focal neurological deficits. On the other hand, in BPPV, episodes of vertigo are usually brief, lasting less than 20 seconds, and only occur when there is a change in head position.

      Further Reading:

      Vestibular neuritis, also known as vestibular neuronitis, is a condition characterized by sudden and prolonged vertigo of peripheral origin. It is believed to be caused by inflammation of the vestibular nerve, often following a viral infection. It is important to note that vestibular neuritis and labyrinthitis are not the same condition, as labyrinthitis involves inflammation of the labyrinth. Vestibular neuritis typically affects individuals between the ages of 30 and 60, with a 1:1 ratio of males to females. The annual incidence is approximately 3.5 per 100,000 people, making it one of the most commonly diagnosed causes of vertigo.

      Clinical features of vestibular neuritis include nystagmus, which is a rapid, involuntary eye movement, typically in a horizontal or horizontal-torsional direction away from the affected ear. The head impulse test may also be positive. Other symptoms include spontaneous onset of rotational vertigo, which is worsened by changes in head position, as well as nausea, vomiting, and unsteadiness. These severe symptoms usually last for 2-3 days, followed by a gradual recovery over a few weeks. It is important to note that hearing is not affected in vestibular neuritis, and symptoms such as tinnitus and focal neurological deficits are not present.

      Differential diagnosis for vestibular neuritis includes benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease, migraine, stroke, and cerebellar lesions. Management of vestibular neuritis involves drug treatment for nausea and vomiting associated with vertigo, typically through short courses of medication such as prochlorperazine or cyclizine. If symptoms are severe and fluids cannot be tolerated, admission and administration of IV fluids may be necessary. General advice should also be given, including avoiding driving while symptomatic, considering the suitability to work based on occupation and duties, and the increased risk of falls. Follow-up is required, and referral is necessary if there are atypical symptoms, symptoms do not improve after a week of treatment, or symptoms persist for more than 6 weeks.

      The prognosis for vestibular neuritis is generally good, with the majority of individuals fully recovering within 6 weeks. Recurrence is thought to occur in 2-11% of cases, and approximately 10% of individuals may develop BPPV following an episode of vestibular neuritis. A very rare complication of vestibular neuritis is ph

    • This question is part of the following fields:

      • Ear, Nose & Throat
      39.7
      Seconds
  • Question 35 - A 6 year old is brought to the emergency department due to the...

    Incorrect

    • A 6 year old is brought to the emergency department due to the sudden appearance of a widespread maculopapular rash. The child's parents express concern as they recently visited relatives in Nigeria where there was a measles outbreak. The symptoms are indicative of measles. What is a potentially severe complication associated with measles?

      Your Answer: Aplastic crisis

      Correct Answer: Subacute sclerosing panencephalitis

      Explanation:

      SSPE, also known as subacute sclerosing panencephalitis, is a serious and potentially deadly complication that can occur as a result of measles. While pneumonia and otitis media are commonly seen complications of measles, SSPE is much rarer. This condition involves inflammation of the brain and is believed to occur either due to the reactivation of the measles virus or an abnormal immune response to the virus.

      Further Reading:

      Measles is a highly contagious viral infection caused by an RNA paramyxovirus. It is primarily spread through aerosol transmission, specifically through droplets in the air. The incubation period for measles is typically 10-14 days, during which patients are infectious from 4 days before the appearance of the rash to 4 days after.

      Common complications of measles include pneumonia, otitis media (middle ear infection), and encephalopathy (brain inflammation). However, a rare but fatal complication called subacute sclerosing panencephalitis (SSPE) can also occur, typically presenting 5-10 years after the initial illness.

      The onset of measles is characterized by a prodrome, which includes symptoms such as irritability, malaise, conjunctivitis, and fever. Before the appearance of the rash, white spots known as Koplik spots can be seen on the buccal mucosa. The rash itself starts behind the ears and then spreads to the entire body, presenting as a discrete maculopapular rash that becomes blotchy and confluent.

      In terms of complications, encephalitis typically occurs 1-2 weeks after the onset of the illness. Febrile convulsions, giant cell pneumonia, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis are also possible complications of measles.

      When managing contacts of individuals with measles, it is important to offer the MMR vaccine to children who have not been immunized against measles. The vaccine-induced measles antibody develops more rapidly than that following natural infection, so it should be administered within 72 hours of contact.

    • This question is part of the following fields:

      • Paediatric Emergencies
      27.4
      Seconds
  • Question 36 - A 3 year old boy is brought into the emergency department by concerned...

    Incorrect

    • A 3 year old boy is brought into the emergency department by concerned parents. The parents inform you that the patient has had a persistent cough and runny nose for the past 2-3 days. However, today they noticed that the patient was having difficulty breathing and was coughing up a lot of mucus. They suspected that the patient might have croup. Upon examination, you hear audible stridor and observe rapid breathing. There are no signs of difficulty swallowing or excessive drooling. The patient is given dexamethasone and nebulized adrenaline, but subsequent observations reveal an increase in respiratory rate and the patient appears increasingly tired.

      What is the most likely underlying diagnosis?

      Your Answer: Epiglottitis

      Correct Answer: Bacterial tracheitis

      Explanation:

      Patients who have bacterial tracheitis usually do not show any improvement when treated with steroids and adrenaline nebulizers. The symptoms of bacterial tracheitis include a prelude of upper respiratory tract infection symptoms, followed by a rapid decline in health with the presence of stridor and difficulty breathing. Despite treatment with steroids and adrenaline, there is no improvement in the patient’s condition. On the other hand, patients with epiglottitis commonly experience difficulty swallowing and excessive saliva production.

      Further Reading:

      Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

      The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

      In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

      Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

      When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies

    • This question is part of the following fields:

      • Paediatric Emergencies
      55.8
      Seconds
  • Question 37 - A 65-year-old patient is presenting with upper gastrointestinal bleeding after receiving heparin. Your...

    Correct

    • A 65-year-old patient is presenting with upper gastrointestinal bleeding after receiving heparin. Your decision is to reverse the anticoagulation process.
      What is the most appropriate option for reversing heparin?

      Your Answer: Protamine sulphate

      Explanation:

      Protamine sulphate is a potent base that forms a stable salt complex with heparin, an acidic substance. This complex renders heparin inactive, making protamine sulphate a useful tool for neutralizing the effects of heparin. Additionally, protamine sulphate can be used to reverse the effects of LMWHs, although it is not as effective, providing only about two-thirds of the relative effect.

      It is important to note that protamine sulphate also possesses its own weak intrinsic anticoagulant effect. This effect is believed to stem from its ability to inhibit the formation and activity of thromboplastin.

      When administering protamine sulphate, it is typically done through slow intravenous injection. The dosage should be adjusted based on the amount of heparin that needs to be neutralized, the time that has passed since heparin administration, and the aPTT (activated partial thromboplastin time). As a general guideline, 1 mg of protamine can neutralize 100 IU of heparin. However, it is crucial to adhere to a maximum adult dose of 50 mg within a 10-minute period.

      It is worth mentioning that protamine sulphate can have some adverse effects. It acts as a myocardial depressant, potentially leading to bradycardia (slow heart rate) and hypotension (low blood pressure). These effects may arise due to complement activation and leukotriene release.

    • This question is part of the following fields:

      • Haematology
      17.2
      Seconds
  • Question 38 - A 32-year-old individual comes in with a history of recent onset morning lower...

    Correct

    • A 32-year-old individual comes in with a history of recent onset morning lower back pain. After being referred and assessed by a specialist, they are diagnosed with spondyloarthritis as the underlying cause of their back pain. Which of the following is the most likely underlying diagnosis?

      Your Answer: Ankylosing spondylitis

      Explanation:

      Spondyloarthritis is a term that encompasses various inflammatory conditions affecting both the joints and the entheses, which are the attachment sites of ligaments and tendons to the bones. The primary cause of spondyloarthritis is ankylosing spondylitis, but it can also be triggered by reactive arthritis, psoriatic arthritis, and enteropathic arthropathies.

      If individuals below the age of 45 experience four or more of the following symptoms, they should be referred for a potential diagnosis of spondyloarthritis:

      – Presence of low back pain and being younger than 35 years old
      – Waking up in the second half of the night due to pain
      – Buttock pain
      – Pain that improves with movement or within 48 hours of using nonsteroidal anti-inflammatory drugs (NSAIDs)
      – Having a first-degree relative with spondyloarthritis
      – History of current or past arthritis, psoriasis, or enthesitis.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      17.4
      Seconds
  • Question 39 - A 25-year-old is brought into the emergency department after being discovered unresponsive in...

    Correct

    • A 25-year-old is brought into the emergency department after being discovered unresponsive in a neighbor's backyard. It is suspected that the patient had consumed alcohol at a nearby bar and opted to walk home in the snowy conditions. The patient's temperature is documented as 27.8ºC. The nurse connects leads to conduct a 12-lead ECG. Which of the subsequent ECG alterations is most closely linked to hypothermia?

      Your Answer: Osborne Waves (J waves)

      Explanation:

      Hypothermia can cause various changes in an electrocardiogram (ECG). These changes include a slower heart rate (bradycardia), the presence of Osborn waves (also known as J waves), a prolonged PR interval, a widened QRS complex, and a prolonged QT interval. Additionally, shivering artifact, ventricular ectopics (abnormal heartbeats originating from the ventricles), and even cardiac arrest (ventricular tachycardia, ventricular fibrillation, or asystole) may occur.

      Further Reading:

      Hypothermic cardiac arrest is a rare situation that requires a tailored approach. Resuscitation is typically prolonged, but the prognosis for young, previously healthy individuals can be good. Hypothermic cardiac arrest may be associated with drowning. Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, basal metabolic rate falls and cell signaling between neurons decreases, leading to reduced tissue perfusion. Signs and symptoms of hypothermia progress as the core temperature drops, initially presenting as compensatory increases in heart rate and shivering, but eventually ceasing as the temperature drops into moderate hypothermia territory.

      ECG changes associated with hypothermia include bradyarrhythmias, Osborn waves, prolonged PR, QRS, and QT intervals, shivering artifact, ventricular ectopics, and cardiac arrest. When managing hypothermic cardiac arrest, ALS should be initiated as per the standard ALS algorithm, but with modifications. It is important to check for signs of life, re-warm the patient, consider mechanical ventilation due to chest wall stiffness, adjust dosing or withhold drugs due to slowed drug metabolism, and correct electrolyte disturbances. The resuscitation of hypothermic patients is often prolonged and may continue for a number of hours.

      Pulse checks during CPR may be difficult due to low blood pressure, and the pulse check is prolonged to 1 minute for this reason. Drug metabolism is slowed in hypothermic patients, leading to a build-up of potentially toxic plasma concentrations of administered drugs. Current guidance advises withholding drugs if the core temperature is below 30ºC and doubling the drug interval at core temperatures between 30 and 35ºC. Electrolyte disturbances are common in hypothermic patients, and it is important to interpret results keeping the setting in mind. Hypoglycemia should be treated, hypokalemia will often correct as the patient re-warms, ABG analyzers may not reflect the reality of the hypothermic patient, and severe hyperkalemia is a poor prognostic indicator.

      Different warming measures can be used to increase the core body temperature, including external passive measures such as removal of wet clothes and insulation with blankets, external active measures such as forced heated air or hot-water immersion, and internal active measures such as inhalation of warm air, warmed intravenous fluids, gastric, bladder, peritoneal and/or pleural lavage and high volume renal haemofilter.

    • This question is part of the following fields:

      • Cardiology
      16.8
      Seconds
  • Question 40 - A 70-year-old patient comes in after a chronic overdose of digoxin. She has...

    Incorrect

    • A 70-year-old patient comes in after a chronic overdose of digoxin. She has experienced multiple episodes of vomiting, feels extremely tired, and reports that her vision seems to have a yellow tint.

      What is the indication for administering DigiFab in this patient?

      Your Answer: Recurrent seizures

      Correct Answer: Coexistent renal failure

      Explanation:

      Digoxin-specific antibody (DigiFab) is an antidote used to counteract digoxin overdose. It is a purified and sterile preparation of digoxin-immune ovine Fab immunoglobulin fragments. These fragments are derived from healthy sheep that have been immunized with a digoxin derivative called digoxin-dicarboxymethoxylamine (DDMA). DDMA is a digoxin analogue that contains the essential cyclopentanoperhydrophenanthrene: lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).

      DigiFab has a higher affinity for digoxin compared to the affinity of digoxin for its sodium pump receptor, which is believed to be the receptor responsible for its therapeutic and toxic effects. When administered to a patient who has overdosed on digoxin, DigiFab binds to digoxin molecules, reducing the levels of free digoxin in the body. This shift in equilibrium away from binding to the receptors helps to reduce the cardiotoxic effects of digoxin. The Fab-digoxin complexes are then eliminated from the body through the kidney and reticuloendothelial system.

      The indications for using DigiFab in cases of acute and chronic digoxin toxicity are summarized below:

      Acute digoxin toxicity:
      – Cardiac arrest
      – Life-threatening arrhythmia
      – Potassium level >5 mmol/l
      – Ingestion of >10 mg of digoxin (in adults)
      – Ingestion of >4 mg of digoxin (in children)
      – Digoxin level >12 ng/ml

      Chronic digoxin toxicity:
      – Cardiac arrest
      – Life-threatening arrhythmia
      – Significant gastrointestinal symptoms
      – Symptoms of digoxin toxicity in the presence of renal failure

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      20.4
      Seconds
  • Question 41 - A 52 year old male is brought into the emergency room after an...

    Correct

    • A 52 year old male is brought into the emergency room after an accident at a construction site resulting in a severe blunt abdominal injury. The patient is experiencing hypotension. The surgical team is preparing for immediate transfer to the operating room. The consultant requests you to prepare intravenous ketamine for rapid sequence induction. What would be the appropriate initial dose of IV ketamine for this patient?

      Your Answer: 1.5 mg/kg IV

      Explanation:

      The recommended dose of ketamine for rapid sequence intubation (RSI) is typically 1.5 mg/kg administered intravenously. This dosage is commonly used in UK medical centers. According to the British National Formulary (BNF), intravenous induction doses of ketamine range from 0.5 to 2 mg/kg for longer procedures and 1 to 4.5 mg/kg for shorter procedures. Ketamine is known to cause an increase in blood pressure, making it a suitable option for individuals with hemodynamic compromise.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
      17.2
      Seconds
  • Question 42 - A 45-year-old man receives a blood transfusion for anemia secondary to gastrointestinal bleeding....

    Correct

    • A 45-year-old man receives a blood transfusion for anemia secondary to gastrointestinal bleeding. During the transfusion, he complains of experiencing alternating sensations of heat and cold during the second unit, and his temperature is measured at 38.1ºC. His temperature before the transfusion was measured at 37ºC. He feels fine otherwise and does not have any other symptoms.
      Which of the following transfusion reactions is most likely to have taken place?

      Your Answer: Febrile transfusion reaction

      Explanation:

      Blood transfusion is a crucial medical treatment that can save lives, but it also comes with various risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there have been improvements in safety procedures and a reduction in transfusion use, errors and adverse reactions still occur. One common adverse reaction is febrile transfusion reactions, which present as an unexpected rise in temperature during or after transfusion. This can be caused by cytokine accumulation or recipient antibodies reacting to donor antigens. Treatment for febrile transfusion reactions is supportive, and other potential causes should be ruled out.

      Another serious complication is acute haemolytic reaction, which is often caused by ABO incompatibility due to administration errors. This reaction requires the transfusion to be stopped and IV fluids to be administered. Delayed haemolytic reactions can occur several days after a transfusion and may require monitoring and treatment for anaemia and renal function. Allergic reactions, TRALI (Transfusion Related Acute Lung Injury), TACO (Transfusion Associated Circulatory Overload), and GVHD (Graft-vs-Host Disease) are other potential complications that require specific management approaches.

      In summary, blood transfusion carries risks and potential complications, but efforts have been made to improve safety procedures. It is important to be aware of these complications and to promptly address any adverse reactions that may occur during or after a transfusion.

    • This question is part of the following fields:

      • Haematology
      18
      Seconds
  • Question 43 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department.
      Which ONE statement about the utilization of amiodarone in cardiac arrest is accurate?

      Your Answer: It is indicated in PEA arrests

      Correct Answer: It increases the duration of the action potential

      Explanation:

      Amiodarone is a medication that is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while chest compressions are being performed. The prescribed dose is 300 mg, given as an intravenous bolus that is diluted in 5% dextrose to a volume of 20 mL. It is important to note that amiodarone is not suitable for treating PEA or asystole.

      In cases where VF/pVT persists after five defibrillation attempts, an additional dose of 150 mg of amiodarone should be given. However, if amiodarone is not available, lidocaine can be used as an alternative. The recommended dose of lidocaine is 1 mg/kg. It is crucial to avoid administering lidocaine if amiodarone has already been given.

      Amiodarone is classified as a membrane-stabilizing antiarrhythmic drug. It works by prolonging the duration of the action potential and the refractory period in both the atrial and ventricular myocardium. This medication also slows down atrioventricular conduction and has a similar effect on accessory pathways.

      Additionally, amiodarone has a mild negative inotropic action, meaning it weakens the force of heart contractions. It also causes peripheral vasodilation through non-competitive alpha-blocking effects.

      It is important to note that while there is no evidence of long-term benefits from using amiodarone, it may improve short-term survival rates, which justifies its continued use.

    • This question is part of the following fields:

      • Cardiology
      20.7
      Seconds
  • Question 44 - A 68-year-old woman with a history of chronic anemia receives a blood transfusion...

    Correct

    • A 68-year-old woman with a history of chronic anemia receives a blood transfusion as part of her treatment plan. She has a known history of heart failure and takes bisoprolol and furosemide. Her most recent BNP level was measured at 123 pmol/l. Five hours after starting the transfusion, she experiences shortness of breath and her existing peripheral edema worsens. Her blood pressure increases to 170/105 mmHg and her BNP level is rechecked, now measuring 192 pmol/l.

      Which of the following treatment options is the most appropriate?

      Your Answer: Slow the transfusion rate and administer diuretics

      Explanation:

      Blood transfusion is a potentially life-saving treatment that can provide great clinical benefits. However, it also carries several risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there has been an increased awareness of these risks and improved reporting systems, transfusion errors and serious adverse reactions still occur and may go unreported.

      One specific transfusion reaction is transfusion-associated circulatory overload (TACO), which occurs when a large volume of blood is rapidly infused. It is the second leading cause of transfusion-related deaths, accounting for about 20% of fatalities. TACO is more likely to occur in patients with diminished cardiac reserve or chronic anemia, particularly in the elderly, infants, and severely anemic patients.

      The typical clinical features of TACO include acute respiratory distress, tachycardia, hypertension, acute or worsening pulmonary edema on chest X-ray, and evidence of positive fluid balance. The B-type natriuretic peptide (BNP) can be a useful diagnostic tool for TACO, with levels usually elevated to at least 1.5 times the pre-transfusion baseline.

      In many cases, simply slowing the transfusion rate, placing the patient in an upright position, and administering diuretics can be sufficient for managing TACO. In more severe cases, the transfusion should be stopped, and non-invasive ventilation may be considered.

    • This question is part of the following fields:

      • Haematology
      27.2
      Seconds
  • Question 45 - A 45 year old patient presents to the emergency department with a head...

    Correct

    • A 45 year old patient presents to the emergency department with a head laceration sustained following a fall while under the influence of alcohol. You determine to evaluate the patient's alcohol consumption. Which screening tool does NICE (National Institute for Health and Care Excellence) recommend for assessing risky drinking?

      Your Answer: AUDIT

      Explanation:

      The AUDIT screening tool is recommended by NICE for identifying patients who may be at risk of hazardous drinking.

      Alcoholic liver disease (ALD) is a spectrum of disease that ranges from fatty liver at one end to alcoholic cirrhosis at the other. Fatty liver is generally benign and reversible with alcohol abstinence, while alcoholic cirrhosis is a more advanced and irreversible form of the disease. Alcoholic hepatitis, which involves inflammation of the liver, can lead to the development of fibrotic tissue and cirrhosis.

      Several factors can increase the risk of progression of ALD, including female sex, genetics, advanced age, induction of liver enzymes by drugs, and co-existent viral hepatitis, especially hepatitis C.

      The development of ALD is multifactorial and involves the metabolism of alcohol in the liver. Alcohol is metabolized to acetaldehyde and then acetate, which can result in the production of damaging reactive oxygen species. Genetic polymorphisms and co-existing hepatitis C infection can enhance the pathological effects of alcohol metabolism.

      Patients with ALD may be asymptomatic or present with non-specific symptoms such as abdominal discomfort, vomiting, or anxiety. Those with alcoholic hepatitis may have fever, anorexia, and deranged liver function tests. Advanced liver disease can manifest with signs of portal hypertension and cirrhosis, such as ascites, varices, jaundice, and encephalopathy.

      Screening tools such as the AUDIT questionnaire can be used to assess alcohol consumption and identify hazardous or harmful drinking patterns. Liver function tests, FBC, and imaging studies such as ultrasound or liver biopsy may be performed to evaluate liver damage.

      Management of ALD involves providing advice on reducing alcohol intake, administering thiamine to prevent Wernicke’s encephalopathy, and addressing withdrawal symptoms with benzodiazepines. Complications of ALD, such as intoxication, encephalopathy, variceal bleeding, ascites, hypoglycemia, and coagulopathy, require specialized interventions.

      Heavy alcohol use can also lead to thiamine deficiency and the development of Wernicke Korsakoff’s syndrome, characterized by confusion, ataxia, hypothermia, hypotension, nystagmus, and vomiting. Prompt treatment is necessary to prevent progression to Korsakoff’s psychosis.

      In summary, alcoholic liver disease is a spectrum of disease that can range from benign fatty liver to irreversible cirrhosis. Risk factors for progression include female sex, genetics, advanced age, drug-induced liver enzyme induction, and co-existing liver conditions.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      13.8
      Seconds
  • Question 46 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Correct

    • A 35-year-old woman is brought in by ambulance following a car accident where her car was hit by a truck. She has sustained severe facial injuries and shows signs of airway obstruction. Her cervical spine is immobilized. The anesthesiologist has attempted to intubate her but is unsuccessful and decides to perform a surgical cricothyroidotomy.

      Which of the following statements regarding surgical cricothyroidotomy is FALSE?

      Your Answer: It is the surgical airway of choice in patients under the age of 12

      Explanation:

      A surgical cricothyroidotomy is a procedure performed in emergency situations to secure the airway by making an incision in the cricothyroid membrane. It is also known as an emergency surgical airway (ESA) and is typically done when intubation and oxygenation are not possible.

      There are certain conditions in which a surgical cricothyroidotomy should not be performed. These include patients who are under 12 years old, those with laryngeal fractures or pre-existing or acute laryngeal pathology, individuals with tracheal transection and retraction of the trachea into the mediastinum, and cases where the anatomical landmarks are obscured due to trauma.

      The procedure is carried out in the following steps:
      1. Gathering and preparing the necessary equipment.
      2. Positioning the patient on their back with the neck in a neutral position.
      3. Sterilizing the patient’s neck using antiseptic swabs.
      4. Administering local anesthesia, if time permits.
      5. Locating the cricothyroid membrane, which is situated between the thyroid and cricoid cartilage.
      6. Stabilizing the trachea with the left hand until it can be intubated.
      7. Making a transverse incision through the cricothyroid membrane.
      8. Inserting the scalpel handle into the incision and rotating it 90°. Alternatively, a haemostat can be used to open the airway.
      9. Placing a properly-sized, cuffed endotracheal tube (usually a size 5 or 6) into the incision, directing it into the trachea.
      10. Inflating the cuff and providing ventilation.
      11. Monitoring for chest rise and auscultating the chest to ensure adequate ventilation.
      12. Securing the airway to prevent displacement.

      Potential complications of a surgical cricothyroidotomy include aspiration of blood, creation of a false passage into the tissues, subglottic stenosis or edema, laryngeal stenosis, hemorrhage or hematoma formation, laceration of the esophagus or trachea, mediastinal emphysema, and vocal cord paralysis or hoarseness.

    • This question is part of the following fields:

      • Trauma
      31.7
      Seconds
  • Question 47 - A 16 year old female arrives at the emergency department after falling off...

    Correct

    • A 16 year old female arrives at the emergency department after falling off a skateboard. X-ray confirms a dislocated shoulder. She doesn't want her parents notified about the injury. You inform the patient that the shoulder will need to be reduced under sedation. After conversing with the patient, you are confident that she has comprehended the information provided and possesses the capacity to consent to treatment. What is the term used to describe a young person's ability to give consent for medical treatment?

      Your Answer: Gillick competence

      Explanation:

      Gillick competence is a legal concept that determines whether a child under the age of 16 has the ability to give consent for their own medical treatment, even without parental consent or knowledge. This term originated in England and Wales and is commonly used in medical law. On the other hand, Fraser guidelines are specifically applied to situations involving advice and treatment related to a young person’s sexual health and contraception.

      Further Reading:

      Patients have the right to determine what happens to their own bodies, and for consent to be valid, certain criteria must be met. These criteria include the person being informed about the intervention, having the capacity to consent, and giving consent voluntarily and freely without any pressure or undue influence.

      In order for a person to be deemed to have capacity to make a decision on a medical intervention, they must be able to understand the decision and the information provided, retain that information, weigh up the pros and cons, and communicate their decision.

      Valid consent can only be provided by adults, either by the patient themselves, a person authorized under a Lasting Power of Attorney, or someone with the authority to make treatment decisions, such as a court-appointed deputy or a guardian with welfare powers.

      In the UK, patients aged 16 and over are assumed to have the capacity to consent. If a patient is under 18 and appears to lack capacity, parental consent may be accepted. However, a young person of any age may consent to treatment if they are considered competent to make the decision, known as Gillick competence. Parental consent may also be given by those with parental responsibility.

      The Fraser guidelines apply to the prescription of contraception to under 16’s without parental involvement. These guidelines allow doctors to provide contraceptive advice and treatment without parental consent if certain criteria are met, including the young person understanding the advice, being unable to be persuaded to inform their parents, and their best interests requiring them to receive contraceptive advice or treatment.

      Competent adults have the right to refuse consent, even if it is deemed unwise or likely to result in harm. However, there are exceptions to this, such as compulsory treatment authorized by the mental health act or if the patient is under 18 and refusing treatment would put their health at serious risk.

      In emergency situations where a patient is unable to give consent, treatment may be provided without consent if it is immediately necessary to save their life or prevent a serious deterioration of their condition. Any treatment decision made without consent must be in the patient’s best interests, and if a decision is time-critical and the patient is unlikely to regain capacity in time, a best interest decision should be made. The treatment provided should be the least restrictive on the patient’s future choices.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      30
      Seconds
  • Question 48 - A 35-year-old woman comes in with sharp pain during bowel movements. The pain...

    Correct

    • A 35-year-old woman comes in with sharp pain during bowel movements. The pain usually continues for an additional 30-60 minutes afterward. She has also observed spots of bright red blood on the toilet paper when wiping. She has been experiencing constipation for the past few weeks.

      What is the MOST suitable initial treatment option for this situation?

      Your Answer: Topical diltiazem

      Explanation:

      An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline, and they are often caused by the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.

      Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last for up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.

      The initial management approach for an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)

      Sphincterotomy, a surgical procedure, should be reserved for cases where the fissure does not heal with conservative measures. It has a success rate of 90%.

    • This question is part of the following fields:

      • Surgical Emergencies
      16.1
      Seconds
  • Question 49 - You assess a 42-year-old woman who has a background of schizophrenia. She was...

    Correct

    • You assess a 42-year-old woman who has a background of schizophrenia. She was initiated on an atypical antipsychotic drug a few months ago and has since experienced significant weight gain.
      Which SPECIFIC atypical antipsychotic medication is most likely to be accountable for her weight gain?

      Your Answer: Clozapine

      Explanation:

      Clozapine is the atypical antipsychotic that is most likely to result in notable weight gain. Additionally, it is linked to the emergence of impaired glucose metabolism and metabolic syndrome.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      15.5
      Seconds
  • Question 50 - A 2-month-old baby girl is brought in by her parents with projectile vomiting....

    Correct

    • A 2-month-old baby girl is brought in by her parents with projectile vomiting. She is vomiting approximately every 45 minutes after each feed but remains hungry. On examination, she appears dehydrated, and you can palpate a small mass in the upper abdomen.

      What is the SINGLE most likely diagnosis?

      Your Answer: Infantile hypertrophic pyloric stenosis

      Explanation:

      Infantile hypertrophic pyloric stenosis is a condition characterized by the thickening and enlargement of the smooth muscle in the antrum of the stomach, leading to the narrowing of the pyloric canal. This narrowing can easily cause obstruction. It is a relatively common condition, occurring in about 1 in 500 live births, and is more frequently seen in males than females, with a ratio of 4 to 1. It is most commonly observed in first-born male children, although it can rarely occur in adults as well.

      The main symptom of infantile hypertrophic pyloric stenosis is vomiting, which typically begins between 2 to 8 weeks of age. The vomit is usually non-bilious and forcefully expelled. It tends to occur around 30 to 60 minutes after feeding, leaving the baby hungry despite the vomiting. In some cases, there may be blood in the vomit. Other clinical features include persistent hunger, dehydration, weight loss, and constipation. An enlarged pylorus, often described as olive-shaped, can be felt in the right upper quadrant or epigastric in approximately 95% of cases. This is most noticeable at the beginning of a feed.

      The typical acid-base disturbance seen in this condition is hypochloremic metabolic alkalosis. This occurs due to the loss of hydrogen and chloride ions in the vomit, as well as decreased secretion of pancreatic bicarbonate. The increased bicarbonate ions in the distal tubule of the kidney lead to the production of alkaline urine. Hyponatremia and hypokalemia are also commonly present.

      Ultrasound scanning is the preferred diagnostic tool for infantile hypertrophic pyloric stenosis, as it is reliable and easy to perform. It has replaced barium studies as the investigation of choice.

      Initial management involves fluid resuscitation, which should be tailored to the weight and degree of dehydration. Any electrolyte imbalances should also be corrected.

      The definitive treatment for this condition is surgical intervention, with the Ramstedt pyloromyotomy being the procedure of choice. Laparoscopic pyloromyotomy is also an effective alternative if suitable facilities are available. The prognosis for infants with this condition is excellent, as long as there is no delay in diagnosis and treatment initiation.

    • This question is part of the following fields:

      • Neonatal Emergencies
      17.3
      Seconds
  • Question 51 - A 35-year-old woman has experienced a fracture of the left humerus. During examination,...

    Correct

    • A 35-year-old woman has experienced a fracture of the left humerus. During examination, it is found that she has weakness in extending her wrist and metacarpophalangeal joints, leading to wrist drop and an inability to grip with her left hand. However, she still has preserved extension of the elbow. Additionally, there is a loss of sensation over the dorsal aspect of the forearm from below the elbow to the 1st dorsal interosseous.
      Which nerve has been damaged in this particular case?

      Your Answer: Radial nerve

      Explanation:

      Radial nerve injuries often occur in conjunction with fractures of the humerus. The most common cause of a radial nerve palsy is external compression or trauma to the radial nerve as it passes through the spiral groove in the middle of the humerus.

      There are several factors that can lead to damage of the radial nerve in the spiral groove. These include trauma, such as a fracture in the middle of the humerus, compression known as Saturday night palsy, and iatrogenic causes like injections.

      When the radial nerve is injured within the spiral groove, it results in weakness of the wrist and metacarpophalangeal joints. However, elbow extension is not affected because the branches to the triceps and anconeus muscles originate before the spiral groove. The interphalangeal joints remain unaffected as well, as they are supplied by the median and ulnar nerves. Sensory loss will be experienced over the dorsal aspect of the forearm, extending from below the elbow to the 1st dorsal interosseous.

      In contrast, injury to the radial nerve in the axilla will also cause weakness of elbow extension and sensory loss in the distribution of the more proximal cutaneous branches. This helps distinguish it from injury in the spiral groove.

      In the forearm, the posterior interosseous branch of the radial nerve can also be damaged. This can occur due to injury to the radial head or entrapment in the supinator muscle under the arcade of Frohse. However, this type of injury can be easily distinguished from injury in the spiral groove because there is no sensory involvement and no wrist drop, thanks to the preservation of the extensor carpi radialis longus. Nonetheless, there will still be weakness in the wrist and fingers.

    • This question is part of the following fields:

      • Neurology
      15.7
      Seconds
  • Question 52 - A 42 year old man is brought into the emergency department after a...

    Correct

    • A 42 year old man is brought into the emergency department after a car accident. He has significant bruising on the right side of his chest. You suspect he may have a hemothorax. When would thoracotomy be considered as a treatment option?

      Your Answer: Prompt drainage of ≥1500 ml of blood following chest drain insertion

      Explanation:

      Thoracotomy is recommended when there is a need for prompt drainage of at least 1500 ml of blood following the insertion of a chest drain. Additionally, it is indicated when there is a continuous blood loss of more than 200 ml per hour for a period of 2-4 hours or when there is a persistent requirement for blood transfusion.

      Further Reading:

      Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.

      The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.

      In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.

    • This question is part of the following fields:

      • Trauma
      20.1
      Seconds
  • Question 53 - A 25-year-old man comes in with a persistent sore throat that has lasted...

    Incorrect

    • A 25-year-old man comes in with a persistent sore throat that has lasted for five days. He denies having a cough. During the examination, his temperature is measured at 39°C and a few tender anterior cervical lymph nodes are found. There is a noticeable amount of exudate on his right tonsil, which appears red and inflamed.

      What is his FeverPAIN score?

      Your Answer: 2

      Correct Answer: 4

      Explanation:

      The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.

      If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.

      The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.

      Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      21.2
      Seconds
  • Question 54 - A 30-year-old woman suffers a gunshot wound to the chest in a domestic...

    Correct

    • A 30-year-old woman suffers a gunshot wound to the chest in a domestic dispute. A FAST scan is performed, which shows the presence of intra-thoracic free fluid.

      Which of the following organs is most likely to be injured in this case?

      Your Answer: Small bowel

      Explanation:

      Low-velocity gunshot wounds to the abdomen result in tissue damage through laceration and cutting. On the other hand, high-velocity gunshot wounds transfer a greater amount of kinetic energy to the abdominal viscera. These types of wounds can cause more extensive damage in the surrounding area of the missile’s path due to temporary cavitation.

      When patients experience penetrating abdominal trauma as a result of gunshot wounds, certain organs are more commonly injured. The small bowel is affected in approximately 50% of cases, followed by the colon in 40% of cases. The liver is injured in around 30% of cases, while abdominal vascular structures are affected in about 25% of cases.

      Please note that these statistics have been obtained from the most recent edition of the ATLS manual.

    • This question is part of the following fields:

      • Trauma
      19.3
      Seconds
  • Question 55 - A 25-year-old woman presents with an anaphylactic reaction after consuming a peanut. What...

    Correct

    • A 25-year-old woman presents with an anaphylactic reaction after consuming a peanut. What is the MOST suitable initial step in her management?

      Your Answer: Administer IM adrenaline

      Explanation:

      When dealing with an anaphylactic reaction, it is important to remove the trigger if it is easily accessible. However, it is not realistic to try and remove a peanut that has already been swallowed, and it is advised against attempting to induce vomiting in the patient.

      In cases where an anaphylactic reaction has been confirmed, it is crucial to administer 500 micrograms of adrenaline immediately.

    • This question is part of the following fields:

      • Allergy
      9.9
      Seconds
  • Question 56 - A 35-year-old patient with a history of exhaustion and weariness has a complete...

    Incorrect

    • A 35-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals the presence of macrocytic anemia.
      What is the most probable underlying diagnosis?

      Your Answer: Chronic renal failure

      Correct Answer: Liver disease

      Explanation:

      Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).

      On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.

      Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.

      It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Haematology
      22.5
      Seconds
  • Question 57 - A 7-year-old girl presents with a 4-day history of blurred vision in her...

    Correct

    • A 7-year-old girl presents with a 4-day history of blurred vision in her left eye. She is also experiencing eye pain and fatigue. On examination, her temperature is 38.0°C, but her other vital signs are normal. There is significant redness in the conjunctiva, and a collection of pus (hypopyon) is present in her left eye. Her visual acuity in that eye is reduced to counting fingers. She recently received a kitten as a pet from her parents.

      What is the SINGLE most likely causative organism?

      Your Answer: Toxocara canis

      Explanation:

      Toxocariasis is a rare infection caused by the parasitic roundworm Toxocara canis. The main way it spreads to humans is through contact with dog feces. However, practicing good hand hygiene can help prevent transmission. While most people who come into contact with Toxocara canis don’t show any symptoms, a small number may experience a mild flu-like illness.

      The most common presentation of toxocariasis is in children, who may experience unilateral visual loss. This loss of vision is typically caused by conditions such as vitritis, macular edema, and tractional retinal detachment. It is believed that these lesions occur due to a toxic or immunoallergic reaction to the larval antigens.

    • This question is part of the following fields:

      • Ophthalmology
      26.6
      Seconds
  • Question 58 - A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with...

    Incorrect

    • A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Wernicke's encephalopathy. You have been requested to examine the patient and arrange an investigation to assist in confirming the diagnosis.

      Which of the following investigations is MOST LIKELY to be beneficial in establishing the diagnosis?

      Your Answer: CT scan of brain

      Correct Answer: MRI scan of brain

      Explanation:

      Wernicke’s encephalopathy is a condition that is linked to alcohol abuse and other causes of thiamine deficiency. It is commonly identified by the presence of three main symptoms: acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination). Additional signs may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. Most cases also involve peripheral neuropathy, primarily affecting the legs.

      This condition is characterized by the occurrence of acute capillary hemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be detected through MRI scanning, while CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will develop a condition known as Korsakoff psychosis. This condition is characterized by retrograde amnesia (loss of memory for events that occurred before the onset of amnesia), an inability to form new memories, disordered perception of time, and confabulation (fabrication of false memories).

      When Wernicke’s encephalopathy is suspected, it is crucial to administer parenteral thiamine (such as Pabrinex) for at least 5 days. Following the parenteral therapy, oral thiamine should be continued.

    • This question is part of the following fields:

      • Neurology
      23.9
      Seconds
  • Question 59 - A 45-year-old woman experiences excessive bleeding after a minor surgical procedure. Her blood...

    Correct

    • A 45-year-old woman experiences excessive bleeding after a minor surgical procedure. Her blood test results are as follows:
      Hemoglobin (Hb): 11.6 g/dl (12-15 g/dl)
      Mean Corpuscular Volume (MCV): 80 fl (80-100 fl)
      Platelets: 246 x 109/l (150-400 x 109/l)
      Bleeding time: 9 minutes (2-7 minutes)
      Prothrombin time: 12 seconds (10-14 seconds)
      Thrombin time: 16 seconds (15-19 seconds)
      Activated Partial Thromboplastin Time (APTT): 64 seconds (35-45 seconds)

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Von Willebrand disease

      Explanation:

      Von Willebrand disease (vWD) is a common hereditary coagulation disorder that affects approximately 1 in 100 individuals. It occurs due to a deficiency in Von Willebrand factor (vWF), which plays a crucial role in blood clotting. vWF not only binds to factor VIII to protect it from rapid breakdown, but it is also necessary for proper platelet adhesion. When vWF is lacking, both factor VIII levels and platelet function are affected, leading to prolonged APTT and bleeding time. However, the platelet count and thrombin time remain unaffected.

      While some individuals with vWD may not experience any symptoms and are diagnosed incidentally during a clotting profile check, others may present with easy bruising, nosebleeds (epistaxis), and heavy menstrual bleeding (menorrhagia). In severe cases, more significant bleeding and joint bleeding (haemarthrosis) can occur.

      For mild cases of von Willebrand disease, bleeding can be managed with desmopressin. This medication works by stimulating the release of vWF stored in the Weibel-Palade bodies, which are storage granules found in the endothelial cells lining the blood vessels and heart. By increasing the patient’s own levels of vWF, desmopressin helps improve clotting. In more severe cases, replacement therapy is necessary. This involves infusing cryoprecipitate or Factor VIII concentrate to provide the missing vWF. Replacement therapy is particularly recommended for patients with severe von Willebrand’s disease who are undergoing moderate or major surgical procedures.

    • This question is part of the following fields:

      • Haematology
      38.6
      Seconds
  • Question 60 - A 62 year old female is brought to the emergency department by her...

    Incorrect

    • A 62 year old female is brought to the emergency department by her husband who is concerned that the patient has been experiencing abdominal pain and also appears slightly confused. He informs you that the patient is a heavy drinker and you observe that the patient was diagnosed with liver cirrhosis 8 months ago. The patient has difficulty focusing during the Abbreviated Mental Test Score (AMTS) but scores 7/10. Upon examination, you notice mild ascites. You suspect the patient has moderate (grade 2) hepatic encephalopathy secondary to liver cirrhosis. The patient's initial blood tests are as follows:

      Bilirubin 45 µmol/l
      ALP 210 u/l
      ALT 300 u/l
      γGT 160 u/l
      Albumin 27 g/l
      INR 1.9

      What is this patient's Child Pugh score?

      Your Answer: 9

      Correct Answer: 13

      Explanation:

      This patient’s Child Pugh score is 9. The Child Pugh score is a scoring system used to assess the severity of liver disease and the prognosis of patients with cirrhosis. It takes into account five variables: bilirubin levels, albumin levels, INR (international normalized ratio), ascites, and hepatic encephalopathy. Each variable is assigned a score from 1 to 3, with 3 indicating the most severe impairment.

      In this case, the patient’s bilirubin level is 45 µmol/l, which corresponds to a score of 2. The albumin level is 27 g/l, which also corresponds to a score of 3. The INR is 1.9, which corresponds to a score of 2. The presence of moderate ascites indicates a score of 3. Finally, the patient has moderate hepatic encephalopathy, which corresponds to a score of 3.

      Adding up the scores for each variable, we get a total score of 13. This indicates that the patient has moderate to severe liver disease and a poorer prognosis.

      Further Reading:
      Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.

      Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.

      The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.

      Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.

      Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.

      Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.

      Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      38.2
      Seconds
  • Question 61 - A 52 year old male is brought to the emergency department with severe...

    Incorrect

    • A 52 year old male is brought to the emergency department with severe head and chest injuries. As his Glasgow Coma Scale (GCS) continues to decline, it is determined that intubation is necessary. You begin preparing for rapid sequence induction (RSI). Before administering sodium thiopentone, the patient's blood pressure is measured and found to be 88/58 mmHg. What is the most suitable course of action?

      Your Answer: Reduce dose by 25%

      Correct Answer: Use half normal dose

      Explanation:

      In patients with pre-existing hypovolaemia, the amount of sodium thiopentone administered should be reduced by half. This is because sodium thiopentone can cause venodilation and myocardial depression, which can result in significant hypovolaemia. Alternatively, an induction agent that does not cause hypotension, such as Etomidate, can be used instead. It is important to note that both propofol and thiopentone are known to cause hypotension.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
      30.8
      Seconds
  • Question 62 - A 45-year-old man presents to the Emergency Department with a one-day history of...

    Incorrect

    • A 45-year-old man presents to the Emergency Department with a one-day history of central abdominal pain which has now moved to the right-hand side. His appetite is poor, and he is complaining of nausea. He has a history of chronic constipation and recently had an episode of sudden, unexplained rectal bleeding for which he has been referred to the general surgical outpatient clinic by his GP. His observations are as follows: temperature 38.4°C, HR 112, BP 134/78, RR 18. On examination, he is tender in the right iliac fossa, and his PR examination revealed rectal tenderness.
      What is the SINGLE most likely diagnosis?

      Your Answer: Ischaemic colitis

      Correct Answer: Acute diverticulitis

      Explanation:

      Acute diverticulitis occurs when a diverticulum becomes inflamed or perforated. This inflammation can either stay localized, forming a pericolic abscess, or spread and cause peritonitis. The typical symptoms of acute diverticulitis include abdominal pain (most commonly felt in the lower left quadrant), fever/sepsis, tenderness in the left iliac fossa, the presence of a mass in the left iliac fossa, and rectal bleeding. About 90% of cases involve the sigmoid colon, which is why left iliac fossa pain and tenderness are commonly seen.

      To diagnose acute diverticulitis, various investigations should be conducted. These include blood tests such as a full blood count, urea and electrolytes, C-reactive protein, and blood cultures. Imaging studies like abdominal X-ray, erect chest X-ray, and possibly an abdominal CT scan may also be necessary.

      Complications that can arise from acute diverticulitis include perforation leading to abscess formation or peritonitis, intestinal obstruction, massive rectal bleeding, fistulae, and strictures.

      In the emergency department, the treatment for diverticulitis should involve providing suitable pain relief, administering intravenous fluids, prescribing broad-spectrum antibiotics (such as intravenous co-amoxiclav), and advising the patient to refrain from eating or drinking. It is also important to refer the patient to the on-call surgical team for further management.

      For more information on diverticular disease, you can refer to the NICE Clinical Knowledge Summary.

    • This question is part of the following fields:

      • Surgical Emergencies
      137.8
      Seconds
  • Question 63 - A 70-year-old woman presents with painless hematuria and mild urinary urgency. Urine microscopy...

    Correct

    • A 70-year-old woman presents with painless hematuria and mild urinary urgency. Urine microscopy and culture are normal. On examination, you note that her bladder feels slightly distended. The rest of her examination was entirely normal.
      Which of the following is the MOST appropriate next management step?

      Your Answer: Urgent urology referral

      Explanation:

      All patients who present with painless haematuria should undergo cystoscopy to rule out bladder cancer. This procedure is typically done in an outpatient setting as part of a haematuria clinic, using a flexible cystoscope and local anaesthetic.

      In this case, the likelihood of prostate cancer is much lower due to the patient’s relatively normal prostate examination and mild symptoms of bladder outlet obstruction.

      Bladder cancer is the seventh most common cancer in the UK, with men being three times more likely to develop it than women. The main risk factors for bladder cancer are increasing age and smoking. Approximately 50% of bladder cancers are caused by smoking, which is believed to be due to the presence of certain chemicals that are excreted through the kidneys. Smokers have a 2-6 times higher risk of developing bladder cancer compared to non-smokers.

      Painless macroscopic haematuria is the most common symptom in 80-90% of bladder cancer cases. There are usually no abnormalities found during a standard physical examination.

      According to current recommendations, the following patients should be urgently referred for a urological assessment:
      – Adults over 45 years old with unexplained visible haematuria and no urinary tract infection.
      – Adults over 45 years old with visible haematuria that persists or recurs after successful treatment of a urinary tract infection.
      – Adults aged 60 and over with unexplained non-visible haematuria and either dysuria or an elevated white cell count on a blood test.

      For those aged 60 and over with recurrent or persistent unexplained urinary tract infection, a non-urgent referral for bladder cancer is recommended.

    • This question is part of the following fields:

      • Urology
      36.8
      Seconds
  • Question 64 - A 65 year old female is brought into the emergency department with a...

    Correct

    • A 65 year old female is brought into the emergency department with a one week history of worsening nausea, muscle cramps, fatigue, and weakness. You send urine and blood samples for analysis. The patient's observations and investigation results are shown below:

      Na+ 120 mmol/l
      K+ 5.3 mmol/l
      Urea 6.5 mmol/l
      Creatinine 87 µmol/l
      Glucose 5.5 mmol/l
      Urine osmolality 365 mosmol/kg
      Blood pressure 138/78 mmHg
      Pulse 82 bpm
      Respiration rate 18 bpm
      Oxygen saturations 97% on air

      What is the most likely diagnosis?

      Your Answer: SIADH

      Explanation:

      The patient’s symptoms of nausea, muscle cramps, fatigue, and weakness are consistent with hyponatremia, which is a low sodium level in the blood. The blood test results show a low sodium level (Na+ 120 mmol/l) and normal potassium level (K+ 5.3 mmol/l), which is commonly seen in SIADH.

      Additionally, the urine osmolality of 365 mosmol/kg indicates concentrated urine, which is contrary to what would be expected in diabetes insipidus. In diabetes insipidus, the urine would be dilute due to the inability to concentrate urine properly.

      The patient’s blood pressure, pulse, respiration rate, and oxygen saturations are within normal range, which does not suggest a diagnosis of Addison’s disease or Conn’s syndrome.

      Therefore, based on the symptoms, laboratory results, and urine osmolality, the most likely diagnosis for this patient is SIADH.

      Further Reading:

      Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.

      There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.

      The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.

      Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.

      It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.

    • This question is part of the following fields:

      • Endocrinology
      42.8
      Seconds
  • Question 65 - A 32 year old male attends the emergency department due to sharp chest...

    Correct

    • A 32 year old male attends the emergency department due to sharp chest pain that has come on gradually over the past 48 hours. The patient reports he has general muscle aches and feels more fatigued than usual. The patient indicates the pain is retrosternal and worsens with deep inspiration and lying supine. On auscultation of the chest, a rub is audible that resembles the sound of squeaky leather. The rhythm is regular and quiet heart sounds are noted. Observations are shown below:

      Blood pressure: 112/68 mmHg
      Pulse rate: 92 bpm
      Respiratory rate: 18 rpm
      Temperature: 37.4ºC
      Oxygen saturations: 98% on air

      What is the likely diagnosis?

      Your Answer: Pericarditis

      Explanation:

      Pericardial friction rub is a common finding in pericarditis and is often described as a sound similar to squeaking leather. This patient exhibits symptoms that are consistent with acute pericarditis, including flu-like illness with muscle pain and fatigue, chest pain that worsens when lying down and improves when sitting up or leaning forward, and the presence of a pleural rub. The gradual onset of symptoms rules out conditions like pulmonary embolism or acute myocardial ischemia. It is important to note that while the pericardial rub is often considered part of the classic triad of clinical features, it is only present in about one-third of patients. Additionally, the rub may come and go, so repeated examinations may increase the chances of detecting this sign.

      Further Reading:

      Pericarditis is an inflammation of the pericardium, which is the protective sac around the heart. It can be acute, lasting less than 6 weeks, and may present with chest pain, cough, dyspnea, flu-like symptoms, and a pericardial rub. The most common causes of pericarditis include viral infections, tuberculosis, bacterial infections, uremia, trauma, and autoimmune diseases. However, in many cases, the cause remains unknown. Diagnosis is based on clinical features, such as chest pain, pericardial friction rub, and electrocardiographic changes. Treatment involves symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs), and patients should avoid strenuous activity until symptoms improve. Complicated cases may require treatment for the underlying cause, and large pericardial effusions may need urgent drainage. In cases of purulent effusions, antibiotic therapy is necessary, and steroid therapy may be considered for pericarditis related to autoimmune disorders or if NSAIDs alone are ineffective.

    • This question is part of the following fields:

      • Cardiology
      26.4
      Seconds
  • Question 66 - A 65 year old male presents to the emergency department with sudden onset...

    Correct

    • A 65 year old male presents to the emergency department with sudden onset of central back pain. After evaluation, you order an X-ray which reveals anterior wedging of the L2 vertebra. You suspect the patient may have undiagnosed osteoporosis. Which of the following statements about osteoporosis is correct?

      Your Answer: Osteoporosis is defined as a T-score of less than -2.5

      Explanation:

      Osteoporosis is a condition characterized by weak and brittle bones, making them more prone to fractures. In this case, the patient’s sudden onset of central back pain and the X-ray findings of anterior wedging of the L2 vertebra suggest the possibility of undiagnosed osteoporosis.

      One correct statement about osteoporosis is that it is defined as a T-score of less than -2.5. The T-score is a measure of bone density and is used to diagnose osteoporosis. A T-score of -2.5 or lower indicates a significant decrease in bone density and an increased risk of fractures.

      Skeletal scintigraphy is not used to diagnose osteoporosis. Instead, it is commonly used to evaluate for other conditions such as bone infections or tumors.

      The pubic rami is not the most common site for osteoporotic fractures. Osteoporotic fractures commonly occur in the spine (vertebral fractures), hip, and wrist.

      Osteoporosis is not characterized by increased bone turnover in focal areas of the axial skeleton with a lytic phase followed by a rapid increase in bone formation by osteoblasts in the sclerotic phase. This description is more consistent with a condition called Paget’s disease of bone.

      The prevalence of osteoporosis is not approximately 10% at 50 years of age. The prevalence of osteoporosis increases with age, and it is estimated that around 50% of women and 25% of men over the age of 50 will experience an osteoporotic fracture in their lifetime.

      Further Reading:

      Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.

      Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.

      The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.

      There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.

      Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.

      Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.

      Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      41.9
      Seconds
  • Question 67 - A 65-year-old woman comes in with lower abdominal discomfort and rectal bleeding. An...

    Correct

    • A 65-year-old woman comes in with lower abdominal discomfort and rectal bleeding. An abdominal CT scan is conducted and reveals a diagnosis of diverticulitis.
      Which part of her large intestine is most likely to be impacted?

      Your Answer: Sigmoid colon

      Explanation:

      Diverticulitis primarily affects the sigmoid colon in about 90% of cases. As a result, it is more commonly associated with pain in the left iliac fossa.

    • This question is part of the following fields:

      • Surgical Emergencies
      9.8
      Seconds
  • Question 68 - You evaluate a 28-year-old patient with burns. Your supervisor recommends referring the patient...

    Incorrect

    • You evaluate a 28-year-old patient with burns. Your supervisor recommends referring the patient to the burns unit. What is a recognized criterion for referral to the burns unit?

      Your Answer: Any burn not healed in 7 days

      Correct Answer: Burn ≥ 3% TBSA (total body surface area) in an adult

      Explanation:

      A recognized criterion for referral to the burns unit is when a burn involves the upper limb, any burn that has not healed in 7 days, any burn with significant blistering, a burn with a pain score on presentation greater than 8 out of 10 on a visual analogue scale, or a burn that covers 3% or more of the total body surface area in an adult.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Surgical Emergencies
      14.9
      Seconds
  • Question 69 - You are requested to deliver a teaching session on delirium for the incoming...

    Correct

    • You are requested to deliver a teaching session on delirium for the incoming medical interns rotating to the emergency department. What is a commonly acknowledged characteristic of delirium?

      Your Answer: Lucid intervals usually occur during the day

      Explanation:

      Delirium is characterized by fluctuating symptoms of disturbed consciousness that typically develop over hours to days. During the day, lucid intervals may occur, while the worst disturbances are often experienced at night. In contrast, dementia has a gradual onset and does not involve fluctuations in mental state. Stroke, on the other hand, is associated with focal neurological deficits.

      Further Reading:

      Delirium is an acute syndrome that causes disturbances in consciousness, attention, cognition, and perception. It is also known as an acute confusional state. The DSM-IV criteria for diagnosing delirium include recent onset of fluctuating awareness, impairment of memory and attention, and disorganized thinking. Delirium typically develops over hours to days and may be accompanied by behavioral changes, personality changes, and psychotic features. It often occurs in individuals with predisposing factors, such as advanced age or multiple comorbidities, when exposed to new precipitating factors, such as medications or infection. Symptoms of delirium fluctuate throughout the day, with lucid intervals occurring during the day and worse disturbances at night. Falling and loss of appetite are often warning signs of delirium.

      Delirium can be classified into three subtypes based on the person’s symptoms. Hyperactive delirium is characterized by inappropriate behavior, hallucinations, and agitation. Restlessness and wandering are common in this subtype. Hypoactive delirium is characterized by lethargy, reduced concentration, and appetite. The person may appear quiet or withdrawn. Mixed delirium presents with signs and symptoms of both hyperactive and hypoactive subtypes.

      The exact pathophysiology of delirium is not fully understood, but it is believed to involve multiple mechanisms, including cholinergic deficiency, dopaminergic excess, and inflammation. The cause of delirium is usually multifactorial, with predisposing factors and precipitating factors playing a role. Predisposing factors include older age, cognitive impairment, frailty, significant injuries, and iatrogenic events. Precipitating factors include infection, metabolic or electrolyte disturbances, cardiovascular disorders, respiratory disorders, neurological disorders, endocrine disorders, urological disorders, gastrointestinal disorders, severe uncontrolled pain, alcohol intoxication or withdrawal, medication use, and psychosocial factors.

      Delirium is highly prevalent in hospital settings, affecting up to 50% of inpatients aged over 65 and occurring in 30% of people aged over 65 presenting to the emergency department. Complications of delirium include increased risk of death, high in-hospital mortality rates, higher mortality rates following hospital discharge, increased length of stay in hospital, nosocomial infections, increased risk of admission to long-term care or re-admission to hospital, increased incidence of dementia, increased risk of falls and associated injuries, pressure sores.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      17
      Seconds
  • Question 70 - A young woman with a previous case of urethritis has a urethral swab...

    Correct

    • A young woman with a previous case of urethritis has a urethral swab sent to the laboratory for examination. Based on the findings of this test, she is diagnosed with gonorrhea.
      What is the most probable observation that would have been made on her urethral swab?

      Your Answer: Gram-negative diplococci

      Explanation:

      Neisseria gonorrhoeae is a type of bacteria that causes the sexually transmitted infection known as gonorrhoea. It is a Gram-negative diplococcus, meaning it appears as pairs of bacteria under a microscope. This infection is most commonly seen in individuals between the ages of 15 and 35, and it is primarily transmitted through sexual contact. One important characteristic of Neisseria gonorrhoeae is its ability to undergo antigenic variation, which means that recovering from an infection does not provide immunity and reinfection is possible.

      When Neisseria gonorrhoeae infects the body, it first attaches to the genitourinary epithelium using pili, which are hair-like structures on the surface of the bacteria. It then invades the epithelial layer and triggers a local acute inflammatory response. In men, the clinical features of gonorrhoea often include urethritis (inflammation of the urethra) in about 80% of cases, dysuria (painful urination) in around 50% of cases, and mucopurulent discharge. Rectal infection may also occur, usually without symptoms, but it can cause anal discharge. Pharyngitis, or inflammation of the throat, is usually asymptomatic in men.

      In women, the clinical features of gonorrhoea commonly include vaginal discharge in about 50% of cases, lower abdominal pain in around 25% of cases, dysuria in 10-15% of cases, and pelvic/lower abdominal tenderness in less than 5% of cases. Endocervical discharge and/or bleeding may also be present. Similar to men, rectal infection is usually asymptomatic but can cause anal discharge, and pharyngitis is usually asymptomatic in women as well.

      Complications of Neisseria gonorrhoeae infection can be serious and include pelvic inflammatory disease (PID) in women, epididymo-orchitis or prostatitis in men, arthritis, dermatitis, pericarditis and/or myocarditis, hepatitis, and meningitis.

      To diagnose gonorrhoea, samples of pus from the urethra, cervix, rectum, or throat should be collected and promptly sent to the laboratory in specialized transport medium. Traditionally, diagnosis has been made using Gram-stain and culture techniques, but newer PCR testing methods are becoming more commonly used.

    • This question is part of the following fields:

      • Sexual Health
      12.1
      Seconds
  • Question 71 - A 52-year-old woman comes in with a persistent sore throat that has lasted...

    Correct

    • A 52-year-old woman comes in with a persistent sore throat that has lasted for five days. She has also been dealing with cold symptoms for the past few days and has a bothersome dry cough. She denies having a fever and her temperature is normal today. During the examination, there are no noticeable swollen lymph nodes in her neck and her throat appears red overall, but her tonsils are not enlarged and there is no visible discharge.

      What is her FeverPAIN score?

      Your Answer: 0

      Explanation:

      The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.

      If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.

      The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.

      Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      16.7
      Seconds
  • Question 72 - One of your consultants is finishing their shift and hands over the management...

    Incorrect

    • One of your consultants is finishing their shift and hands over the management of a 6 year old patient with severe diabetic ketoacidosis (DKA). Which of the following criteria is used to categorize DKA as severe?

      Your Answer: Blood pH < 7.1

      Correct Answer:

      Explanation:

      When a person’s systolic blood pressure is less than 90 mmHg, it indicates low blood pressure. A pulse rate above 100 or below 60 beats per minute is considered abnormal. An anion gap above 16 is indicative of an imbalance in the body’s electrolytes.

      Further Reading:

      Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.

      The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.

      DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.

      The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.

      Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.

      Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.

    • This question is part of the following fields:

      • Endocrinology
      22.3
      Seconds
  • Question 73 - A 21 year old patient is brought into the emergency department with burns...

    Incorrect

    • A 21 year old patient is brought into the emergency department with burns to the left arm. The patient informs you that one of their friends had accidentally set their sleeve on fire with a lighter, causing the material to quickly burn and stick to their skin. The patient's entire left arm is burned, with the front part experiencing superficial partial thickness burns and the back part having areas of deep partial thickness and full thickness burns. What is the estimated total body surface area of burn in this patient?

      Your Answer: 18%

      Correct Answer: 9%

      Explanation:

      To estimate the total body surface area of burn, we need to consider the rule of nines. This rule divides the body into different regions, each representing a certain percentage of the total body surface area. According to the rule of nines, the left arm accounts for 9% of the total body surface area. Therefore, the estimated total body surface area of burn in this patient is 9%.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Trauma
      35.5
      Seconds
  • Question 74 - A 28-year-old woman is diagnosed with tuberculosis during her pregnancy and given anti-tuberculous...

    Correct

    • A 28-year-old woman is diagnosed with tuberculosis during her pregnancy and given anti-tuberculous medication. The mother experiences liver damage, and the newborn experiences seizures and neuropathy.
      Which of the following drugs is the most probable cause of these abnormalities?

      Your Answer: Isoniazid

      Explanation:

      The standard drug regimen for tuberculosis is generally safe to use during pregnancy, with the exception of streptomycin which should be avoided. However, the use of isoniazid during pregnancy has been associated with potential risks such as liver damage in the mother and the possibility of neuropathy and seizures in the newborn.

      Here is a list outlining some commonly encountered drugs that have adverse effects during pregnancy:

      ACE inhibitors (e.g. ramipril): If taken during the second and third trimesters, these medications can lead to reduced blood flow, kidney failure, and a condition called oligohydramnios.

      Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity, resulting in hearing loss in the baby.

      Aspirin: High doses of aspirin can increase the risk of first trimester abortions, delayed labor, premature closure of the fetal ductus arteriosus, and a condition called fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines (e.g. diazepam): When taken late in pregnancy, these medications can cause respiratory depression in the baby and lead to a withdrawal syndrome.

      Calcium-channel blockers: If taken during the first trimester, these drugs can cause abnormalities in the fingers and toes. If taken during the second and third trimesters, they may result in fetal growth retardation.

      Carbamazepine: This medication can increase the risk of hemorrhagic disease in the newborn and neural tube defects.

      Chloramphenicol: Use of this drug in newborns can lead to a condition known as grey baby syndrome.

      Corticosteroids: If taken during the first trimester, corticosteroids may increase the risk of orofacial clefts in the baby.

      Danazol: When taken during the first trimester, this medication can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling crushed or broken tablets of finasteride as it can be absorbed through the skin and affect the development of male sex organs in the baby.

      Haloperidol: If taken during the first trimester, this medication may increase the risk of limb malformations. If taken during the third trimester, it can lead to an increased risk of extrapyramidal symptoms in the newborn.

      Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      13.2
      Seconds
  • Question 75 - A 42-year-old woman comes in with a recent nosebleed. The bleeding was minor...

    Incorrect

    • A 42-year-old woman comes in with a recent nosebleed. The bleeding was minor and has now ceased.
      Which ONE of the following arteries is not involved in Kiesselbach’s plexus?

      Your Answer: Greater palatine artery

      Correct Answer: Posterior ethmoidal artery

      Explanation:

      Kiesselbach’s plexus, also known as Little’s area, is located in the front and lower part of the nasal septum. It is the most common site of bleeding in cases of anterior epistaxis. This plexus is formed by the convergence of four arteries: the anterior ethmoidal artery, the sphenopalatine artery, the greater palatine artery, and the septal branch of the superior labial artery. It is important to note that while the posterior ethmoidal artery supplies the septum of the nose, it does not contribute to Kiesselbach’s plexus.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      27.6
      Seconds
  • Question 76 - A 65 year old is brought into the emergency department (ED) after experiencing...

    Correct

    • A 65 year old is brought into the emergency department (ED) after experiencing a head injury. As part of the initial assessment, you evaluate the patient's Glasgow Coma Scale (GCS) score. In an adult patient, what is the minimum GCS score that necessitates an urgent CT scan of the head?

      Your Answer: 13

      Explanation:

      In an adult patient, a Glasgow Coma Scale (GCS) score of 13 or lower necessitates an urgent CT scan of the head. The GCS is a neurological assessment tool that evaluates a patient’s level of consciousness and neurological functioning. It consists of three components: eye opening, verbal response, and motor response. Each component is assigned a score ranging from 1 to 4 or 5, with a higher score indicating a higher level of consciousness.

      A GCS score of 15 is considered normal and indicates that the patient is fully conscious. A score of 14 or 13 suggests a mild impairment in consciousness, but it may not necessarily require an urgent CT scan unless there are other concerning symptoms or signs. However, a GCS score of 11 or 9 indicates a moderate to severe impairment in consciousness, which raises concerns for a potentially serious head injury. In these cases, an urgent CT scan of the head is necessary to assess for any structural brain abnormalities or bleeding that may require immediate intervention.

      Therefore, in this case, the minimum GCS score that necessitates an urgent CT scan of the head is 13.

      Further Reading:

      Indications for CT Scanning in Head Injuries (Adults):
      – CT head scan should be performed within 1 hour if any of the following features are present:
      – GCS < 13 on initial assessment in the ED
      – GCS < 15 at 2 hours after the injury on assessment in the ED
      – Suspected open or depressed skull fracture
      – Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
      – Post-traumatic seizure
      – New focal neurological deficit
      – > 1 episode of vomiting

      Indications for CT Scanning in Head Injuries (Children):
      – CT head scan should be performed within 1 hour if any of the features in List 1 are present:
      – Suspicion of non-accidental injury
      – Post-traumatic seizure but no history of epilepsy
      – GCS < 14 on initial assessment in the ED for children more than 1 year of age
      – Paediatric GCS < 15 on initial assessment in the ED for children under 1 year of age
      – At 2 hours after the injury, GCS < 15
      – Suspected open or depressed skull fracture or tense fontanelle
      – Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
      – New focal neurological deficit
      – For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

      – CT head scan should be performed within 1 hour if none of the above features are present but two or more of the features in List 2 are present:
      – Loss of consciousness lasting more than 5 minutes (witnessed)
      – Abnormal drowsiness
      – Three or more discrete episodes of vomiting
      – Dangerous mechanism of injury (high-speed road traffic accident, fall from a height of

    • This question is part of the following fields:

      • Neurology
      17.6
      Seconds
  • Question 77 - A 45-year-old patient arrives at the Emergency Department complaining of a severe headache....

    Incorrect

    • A 45-year-old patient arrives at the Emergency Department complaining of a severe headache. This individual is a known heavy drinker, consuming 15-20 units of alcohol daily. It is currently 3 pm, and the patient is visibly intoxicated. Despite the need for assessment, the patient adamantly refuses and insists on leaving.
      What course of action would be most suitable in this situation?

      Your Answer: Refer him to the medical team on-call

      Correct Answer: Suggest a referral to the community drug and alcohol team

      Explanation:

      When considering the management of long-term conditions and promoting patient self-care, it is important to explore various factors. However, out of the given options, the only safe and viable choice is to refer the patient to the community drug and alcohol team. Without further information about the patient’s headache, a CT scan is not necessary. It would be unwise to advise the patient to stop drinking or to allow them to leave the department without assessing their capacity and obtaining their signature on a self-discharge form. At this point, there is insufficient information to make a referral to the medical team.

    • This question is part of the following fields:

      • Mental Health
      20.6
      Seconds
  • Question 78 - You examine the X-ray of a 55-year-old male who has fallen onto his...

    Incorrect

    • You examine the X-ray of a 55-year-old male who has fallen onto his extended right hand. The X-ray confirms a fracture of the distal radius with dorsal displacement. Your plan is to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). While conducting the procedure, you take note of the duration of cuff inflation. What is the maximum duration the cuff should remain inflated?

      Your Answer: 1 hour

      Correct Answer: 45 minutes

      Explanation:

      According to the RCEM, the minimum time for cuff inflation during Bier’s block is 20 minutes, while the maximum time is 45 minutes.

      Further Reading:

      Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

      Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

      During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

      There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

    • This question is part of the following fields:

      • Basic Anaesthetics
      27.9
      Seconds
  • Question 79 - The Emergency Medicine consultant in charge of the department today asks for your...

    Correct

    • The Emergency Medicine consultant in charge of the department today asks for your attention to present a case of superior orbital fissure syndrome (SOFS) in a 30-year-old woman with a Le Fort II fracture of the midface after a car accident.

      Which of the following anatomical structures does NOT traverse through the superior orbital fissure?

      Your Answer: Facial vein

      Explanation:

      The superior orbital fissure is a gap in the back wall of the orbit, created by the space between the greater and lesser wings of the sphenoid bone. Several structures pass through it to enter the orbit, starting from the top and going downwards. These include the lacrimal nerve (a branch of CN V1), the frontal nerve (another branch of CN V1), the superior ophthalmic vein, the trochlear nerve (CN IV), the superior division of the oculomotor nerve (CN III), the nasociliary nerve (a branch of CN V1), the inferior division of the oculomotor nerve (CN III), the abducens nerve (CN VI), and the inferior ophthalmic vein.

      Adjacent to the superior orbital fissure, on the back wall of the orbit and towards the middle, is the optic canal. The optic nerve (CN II) exits the orbit through this canal, along with the ophthalmic artery.

      Superior orbital fissure syndrome (SOFS) is a condition characterized by a combination of symptoms and signs that occur when cranial nerves III, IV, V1, and VI are compressed or injured as they pass through the superior orbital fissure. This condition also leads to swelling and protrusion of the eye due to impaired drainage and congestion. The main causes of SOFS are trauma, tumors, and inflammation. It is important to note that CN II is not affected by this syndrome, as it follows a separate path through the optic canal.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      11.1
      Seconds
  • Question 80 - You are suturing a young patient with a significant laceration. While performing the...

    Correct

    • You are suturing a young patient with a significant laceration. While performing the procedure, the patient begins to express discomfort. You observe that the patient seems restless and their muscles are experiencing spasms. You suspect that the patient is displaying symptoms of local anesthetic toxicity. Apart from following standard ALS protocols, what intravenous medication can be administered in case of a cardiac arrest?

      Your Answer: Intralipid

      Explanation:

      Intralipid is a lipid emulsion that is commonly used as a source of nutrition in parenteral nutrition. However, it has also been found to be effective in treating local anesthetic toxicity. When administered intravenously, Intralipid acts as a lipid sink, meaning it can bind to the local anesthetic agent and remove it from the affected tissues, thereby reversing the toxic effects.

      In cases of cardiac arrest related to local anesthetic toxicity, Intralipid can be administered as a bolus followed by an infusion. The recommended dose is typically 1.5 mL/kg bolus over 1 minute, followed by an infusion of 0.25 mL/kg/minute for 10 minutes. This can be repeated if necessary.

      It is important to note that while Intralipid has shown promising results in treating local anesthetic toxicity, it should not replace standard ALS protocols. Basic life support (BLS) measures, such as cardiopulmonary resuscitation (CPR), should still be initiated immediately, and advanced cardiac life support (ACLS) protocols should be followed.

      Further Reading:

      Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.

      However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.

      The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.

      If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.

      It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      18.2
      Seconds
  • Question 81 - A 45-year-old man develops anaphylaxis following a bee sting. He is taken to...

    Correct

    • A 45-year-old man develops anaphylaxis following a bee sting. He is taken to resus for immediate treatment.

      Which of the following is an absolute contraindication to the administration of adrenaline in an anaphylactic reaction?

      Your Answer: None of these options

      Explanation:

      Adrenaline can be given in cases of life-threatening anaphylactic reactions, even if there are certain conditions that may make it less advisable. These conditions include coronary artery disease, uncontrolled hypertension, serious ventricular arrhythmias, and the second stage of labor. Despite these relative contraindications, adrenaline may still be administered to address the immediate danger posed by anaphylaxis.

    • This question is part of the following fields:

      • Allergy
      27.3
      Seconds
  • Question 82 - You assess a patient who has had ulcerative colitis for 10 years and...

    Correct

    • You assess a patient who has had ulcerative colitis for 10 years and is anxious about the potential risk of developing colon cancer.

      Your Answer: 1 in 50

      Explanation:

      Patients diagnosed with ulcerative colitis face a significantly heightened risk of developing colon cancer. It is crucial for these individuals, especially those with severe or extensive disease, to undergo regular monitoring to detect any potential signs of colon cancer. The risk of developing colon cancer increases as the duration of ulcerative colitis progresses. After 10 years, the risk stands at 1 in 50. After 20 years, the risk increases to 1 in 12. And after 30 years, the risk further rises to 1 in 6. While Crohn’s disease also carries a risk of colonic carcinoma, it is comparatively smaller than that associated with ulcerative colitis.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      11
      Seconds
  • Question 83 - You assess a 50-year-old woman who has a past medical history of hereditary...

    Incorrect

    • You assess a 50-year-old woman who has a past medical history of hereditary angioedema. What is the ONE option that can be utilized for the chronic prevention of this condition?

      Your Answer: C1 esterase inhibitor

      Correct Answer: Tranexamic acid

      Explanation:

      Hereditary angioedema is a condition caused by a lack of C1 esterase inhibitor, a protein that is part of the complement system. It is typically inherited in an autosomal dominant manner. Symptoms usually start in childhood and continue sporadically into adulthood. Attacks can be triggered by minor surgical procedures, dental work, and stress. The main clinical signs of hereditary angioedema include swelling of the skin and mucous membranes, with the face, tongue, and extremities being the most commonly affected areas. There is often a tingling sensation before an attack, sometimes accompanied by a non-itchy rash.

      Angioedema and anaphylaxis resulting from C1 esterase inhibitor deficiency do not respond to adrenaline, steroids, or antihistamines. Treatment requires the use of C1 esterase inhibitor concentrate or fresh frozen plasma, both of which contain C1 esterase inhibitor. In situations that may trigger an attack, short-term prophylaxis can be achieved by administering C1 esterase inhibitor or fresh frozen plasma infusions prior to the event. For long-term prevention, androgenic steroids like stanozolol or antifibrinolytic drugs such as tranexamic acid can be used.

    • This question is part of the following fields:

      • Allergy
      14.5
      Seconds
  • Question 84 - A 72 year old male patient has arrived at the emergency department after...

    Correct

    • A 72 year old male patient has arrived at the emergency department after injuring himself in a fall. Upon reviewing the patient's medical history, you discover that he was diagnosed with mitral stenosis last year. You advise the medical students to assess the patient for indications of this condition.

      What is a typical symptom observed in individuals with mitral stenosis?

      Your Answer: Malar flush

      Explanation:

      One of the clinical features of mitral stenosis is malar flush, which refers to a reddening or flushing of the cheeks. Other clinical features include a mid-late diastolic murmur that is best heard during expiration, a loud S1 heart sound with an opening snap, a low volume pulse, atrial fibrillation, and signs of pulmonary edema such as crepitations or the presence of white or pink frothy sputum.

      Further Reading:

      Mitral Stenosis:
      – Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
      – Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
      – Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
      – Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

      Mitral Regurgitation:
      – Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
      – Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
      – Signs of acute MR: Decompensated congestive heart failure symptoms
      – Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
      – Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

    • This question is part of the following fields:

      • Cardiology
      25.8
      Seconds
  • Question 85 - A 3-year-old boy is brought in by his father with symptoms of fever...

    Correct

    • A 3-year-old boy is brought in by his father with symptoms of fever and irritability. He also complains of lower abdominal pain and stinging during urination. A urine dipstick is performed on a clean catch urine, which reveals the presence of blood, protein, leucocytes, and nitrites. You diagnose him with a urinary tract infection (UTI) and prescribe antibiotics. His blood tests today show that his eGFR is 38 ml/minute. He has no history of other UTIs or infections requiring antibiotics in the past 12 months.
      Which of the following antibiotics is the most appropriate to prescribe in this case?

      Your Answer: Trimethoprim

      Explanation:

      For the treatment of young people under 16 years with lower urinary tract infection (UTI), it is important to obtain a urine sample before starting antibiotics. This sample can be tested using a dipstick or sent for culture and susceptibility testing. In cases where children under 5 present with fever along with lower UTI, it is recommended to follow the guidance outlined in the NICE guideline on fever in under 5s.

      Immediate antibiotic prescription should be offered to children and young people under 16 years with lower UTI. When making this prescription, it is important to consider previous urine culture and susceptibility results, as well as any history of antibiotic use that may have led to resistant bacteria. If a urine sample has been sent for culture and sensitivity testing, the choice of antibiotic should be reviewed once the microbiological results are available. If the bacteria are found to be resistant and symptoms are not improving, a narrow-spectrum antibiotic should be used whenever possible.

      For non-pregnant women aged 16 years and under, the following antibiotics can be considered:
      – Children under 3 months: It is recommended to refer to a pediatric specialist and treat with an intravenous antibiotic in line with the NICE guideline on fever in under 5s.
      – First-choice in children over 3 months: Nitrofurantoin (if eGFR >45 ml/minute) or Trimethoprim (if low risk of resistance*).
      – Second-choice in children over 3 months (when there is no improvement in lower UTI symptoms on first-choice for at least 48 hours, or when first-choice is not suitable): Nitrofurantoin (if eGFR >45 ml/minute and not used as first-choice), Amoxicillin (only if culture results are available and susceptible), or Cefalexin.

      Please refer to the BNF for children for dosing information. It is important to consider the risk of resistance when choosing antibiotics. A lower risk of resistance may be more likely if the antibiotic has not been used in the past 3 months, if previous urine culture suggests susceptibility (but was not used), and in younger people in areas where local epidemiology data suggest low resistance. On the other hand, a higher risk of resistance may be more likely with recent antibiotic use and in older people in residential facilities.

    • This question is part of the following fields:

      • Urology
      18.1
      Seconds
  • Question 86 - A 7-year-old girl comes in with a painful throat and a dry cough...

    Correct

    • A 7-year-old girl comes in with a painful throat and a dry cough that has been bothering her for two days. During the examination, she does not have a fever and has a few tender lymph nodes in the front of her neck. Her throat and tonsils look red and inflamed, but there is no pus on her tonsils.
      What is her FeverPAIN score?

      Your Answer: 2

      Explanation:

      The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.

      If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.

      The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.

      Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      17.3
      Seconds
  • Question 87 - A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his...

    Correct

    • A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his limbs and chest. He is started on regular maintenance treatment with potent opioids for his pain.
      According to NICE, what is the recommended initial rescue medication for breakthrough pain?

      Your Answer: Oral immediate-release morphine

      Explanation:

      When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.

      For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.

      When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.

      In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.

      For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      17.2
      Seconds
  • Question 88 - A 28 year old male comes to the emergency department complaining of a...

    Correct

    • A 28 year old male comes to the emergency department complaining of a sore throat that has been bothering him for the past 2 days. The patient mentions that he has been experiencing a dry cough on and off for the past day or two. During the examination, the patient's temperature is measured at 38.4°C, blood pressure at 132/86 mmHg, and pulse rate at 90 bpm. Both tonsils appear inflamed with white/yellow exudate visible on their surface, and there is tenderness when palpating the enlarged anterior cervical lymph nodes.

      What would be the most appropriate course of action for managing this patient?

      Your Answer: Prescribe phenoxymethylpenicillin 500 mg four times daily for 10 days

      Explanation:

      Phenoxymethylpenicillin is the preferred antibiotic for treating streptococcal sore throat, especially in patients with a CENTOR score of 3/4 and a FeverPAIN score of 4/5. In such cases, antibiotics are necessary to effectively treat the infection.

      Further Reading:

      Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.

      Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.

      When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.

      Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.

      To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      49.6
      Seconds
  • Question 89 - A 40-year-old carpenter comes in with a few weeks of persistent lower back...

    Incorrect

    • A 40-year-old carpenter comes in with a few weeks of persistent lower back pain. Despite taking the maximum dose of ibuprofen, the pain continues to be significant. What would be the most suitable course of treatment? Choose only ONE option.

      Your Answer: Diclofenac sodium

      Correct Answer: Low-dose codeine phosphate

      Explanation:

      The current guidelines from NICE provide recommendations for managing low back pain. It is suggested to consider using oral non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, while taking into account the potential risks of gastrointestinal, liver, and cardio-renal toxicity, as well as the person’s individual risk factors and age. When prescribing oral NSAIDs, it is important to conduct appropriate clinical assessments, monitor risk factors regularly, and consider the use of gastroprotective treatment. It is advised to prescribe the lowest effective dose of oral NSAIDs for the shortest duration possible. In cases where NSAIDs are contraindicated, not tolerated, or ineffective, weak opioids (with or without paracetamol) may be considered for managing acute low back pain. However, NICE does not recommend the use of paracetamol alone, opioids for chronic low back pain, serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors, tricyclic antidepressants for non-neuropathic pain, anticonvulsants, or benzodiazepines for muscle spasm associated with acute low back pain. For more information, you can refer to the NICE guidance on low back pain and sciatica in individuals over 16 years old, as well as the NICE Clinical Knowledge Summary on low back pain without radiculopathy.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      21.1
      Seconds
  • Question 90 - A 67 year old female attends the emergency department complaining of palpitations. The...

    Incorrect

    • A 67 year old female attends the emergency department complaining of palpitations. The patient reports experiencing brief episodes of palpitations over the past few weeks, but they usually resolve themselves after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. She is currently taking aspirin 75mg once daily as her only medication. Blood tests are conducted, and the results are as follows:

      Hemoglobin (Hb): 115 g/l
      Platelets: 155 * 109/l
      White blood cells (WBC): 6.4 * 109/l
      Sodium: 138 mmol/l
      Potassium: 3.8 mmol/l
      Urea: 4.1 mmol/l
      Creatinine: 74 µmol/l
      Glomerular filtration rate (GFR): 68 mL/min/1.73m2

      An electrocardiogram (ECG) is performed, revealing atrial fibrillation. You decide to assess the patient's bleeding risk using the ORBIT tool. What is this patient's ORBIT score?

      Your Answer: 4

      Correct Answer: 3

      Explanation:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

    • This question is part of the following fields:

      • Cardiology
      44.5
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Surgical Emergencies (4/6) 67%
Respiratory (1/2) 50%
Safeguarding & Psychosocial Emergencies (2/2) 100%
Resus (2/2) 100%
Nephrology (1/1) 100%
Urology (3/3) 100%
Trauma (4/5) 80%
Musculoskeletal (non-traumatic) (2/3) 67%
Mental Health (1/3) 33%
Pharmacology & Poisoning (8/9) 89%
Ear, Nose & Throat (6/8) 75%
Haematology (6/7) 86%
Vascular (0/1) 0%
Endocrinology (2/4) 50%
Infectious Diseases (0/1) 0%
Neurology (6/7) 86%
Oncological Emergencies (1/1) 100%
Cardiology (4/6) 67%
Gastroenterology & Hepatology (3/4) 75%
Paediatric Emergencies (0/2) 0%
Basic Anaesthetics (1/3) 33%
Neonatal Emergencies (1/1) 100%
Allergy (2/3) 67%
Ophthalmology (1/1) 100%
Elderly Care / Frailty (2/2) 100%
Sexual Health (1/1) 100%
Maxillofacial & Dental (1/1) 100%
Palliative & End Of Life Care (1/1) 100%
Passmed